Acute Pain Management PDF

Australian and New Zealand College
of Anaesthetists and Faculty of Pain Medicine
ACUTE PAIN
MANAGEMENT:
SCIENTIFIC
EVIDENCE
Fourth Edition 2015
Edited by:
Stephan A Schug
Greta M Palmer
David A Scott
Richard Halliwell
Jane Trinca
This document should be cited as:
Copyright information for Tables 10.1 and 10.2
with permission from Prescribing Medicines in Pregnancy, 2015
Disclaimer
ACUTE PAIN MANAGEMENT:
SCIENTIFIC EVIDENCE
AUSTRALIAN AND NEW ZEALAND

COLLEGE OF ANAESTHETISTS AND
FACULTY OF PAIN MEDICINE
4TH EDITION
FOREWORD
FOREWORD
included the management of acute pain.
iii
enormity of the challenge faced by Prof Stephan Schug and the other members of the
contributors are acknowledged as well.
is to understand and modify the pathogenic mechanisms of the undesirable responses to
book.
Quality and Safety

Anaesthesia
New Zealand
References
FOREWORD
Trend: the future of knowledge
Pain 152
Can J Anaesth 61
Curr Opin Anaesthesiol 28
necessary? Control Clin Trials 17

Anesthesiology.
Curr Opin Anesthesiol 24
Curr Med Res Opin

Crossing the Quality Chasm: A New Health System for the 21st Century
adults. Am J Health Syst Pharm 72
clinician. J Matern Fetal Neonatal Med.
Physiother Can 63:

INTRODUCTION
INTRODUCTION
.
medicine professionals and consumers.
a concise and easily readable form. New and updated content has been incorporated into the
Review of the evidence
Levels of evidence
GL
Levels of evidence
I
II
group
IV
Quality scoring
S
•
Level I
•
GL
Level I
•
GL
Level I
•
Level I
Level I
INTRODUCTION
Level IV SR
Randomised-controlled trials
Level II
Other evidence
Level III and Level IV
Level IV
NR
CR GL
BS
PK EH
Level II PK
Key messages
GL
Review and revision of key messages
New
Unchanged
Strengthened
Weakened
NB
Group members; there was no mandatory threshold of new evidence (eg number
New, U
Acknowledgements
acknowledged.
Cassandra Sparkes for their ongoing input to the process.

References
INTRODUCTION
Int J Technol Assess Health Care

19
BMJ 339
Lancet 354
methodological handbooks. Implement Sci 9

Contents
CONTENTS
FOREWORD ......................................................................................................................... iii
INTRODUCTION .................................................................................................................. vii
SUMMARY OF KEY MESSAGES ..........................................................................................xxiii
1. PHYSIOLOGY AND PSYCHOLOGY OF ACUTE PAIN ........................................................... 1
.......................................................................... 1
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References .................................................................................................................. 33
2. ASSESSMENT AND MEASUREMENT OF PAIN AND PAIN TREATMENT ........................... 43
........................................................................................................ 43
..................................................................................................... 45
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.................................................. 49
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References .................................................................................................................. 51
3. PROVISION OF SAFE AND EFFECTIVE ACUTE PAIN MANAGEMENT ............................... 53
.......................................................................................................... 53
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......................................... 62
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References .................................................................................................................. 64
4. ANALGESIC MEDICINES ............................................................................................... 69
4.1 Opioids ............................................................................................................... 69
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CONTENTS
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........................................................ 143
References ................................................................................................................ 144
5. ADMINISTRATION OF ANALGESIC MEDICINES............................................................ 179
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References ................................................................................................................ 223
6. PATIENT-CONTROLLED ANALGESIA ............................................................................ 241
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........................... 247
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........................................................................... 252
References ................................................................................................................ 253
7. NONPHARMACOLOGICAL TECHNIQUES ..................................................................... 259
.............................................................................. 259
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................................................... 265
CONTENTS
.......................................................................... 265
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........................................................................................... 269
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.........................................................................................
References ................................................................................................................ 271
8. SPECIFIC CLINICAL SITUATIONS .................................................................................. 279
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8.7.7 Acute pain due to bone cancer .................................................................
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References ............................................................................................................... 369
9. THE PAEDIATRIC PATIENT........................................................................................... 409
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CONTENTS
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9.6 Regional analgesia ........................................................................................... 449
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References ................................................................................................................ 485
10. OTHER SPECIFIC PATIENT GROUPS ............................................................................. 515
........................................................................................ 515
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...... 552
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apnoea ............................................................................................................ 558

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of opioids .................................................................................................
References ................................................................................................................ 586
Appendix A ...................................................................................................................... 611
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Appendix B ...................................................................................................................... 621
.......................................................................................................... 621
............................................................................................ 633
Index ................................................................................................................................ 641
CONTENTS
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children ................................................................................................................
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analgesia...............................................................................................................
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SUMMARY OF KEY MESSAGES

1. PHYSIOLOGY AND PSYCHOLOGY OF ACUTE PAIN
Psychological aspects of acute pain
N Level I
N Level III-2 SR
N Level IV SR)
N Level III-2 SR
S Level IV SR S Level IV SR U
Level IV
U Level IV
(U).
Placebo and nocebo effects in acute pain
N Level I
N
Level I
N Level I
N Level II
N Level III-1
N Level II
N
Level II
N
Progression of acute to chronic pain
S Level I
N Level I
S Level I
N Level I
S Level I
N Level III-2 SR
N Level IV SR
S Level IV SR
8. Spinal anaesthesia in comparison to general anaesthesia reduces the risk of chronic
U Level III-2
S Level IV
S Level IV
N
Pre-emptive and preventive analgesia
U Level I
S Level I
S Level I
S Level I
N
Adverse physiological and psychological effects of acute pain
S
Level I
U
Genetics and acute pain

Q Level II
N Level III-2
N
Level IV
U
2. ASSESSMENT AND MEASUREMENT OF PAIN AND PAIN TREATMENT
Assessment and measurement
U Level III-3
S Level IV SR
N Level IV
U
Outcome measures in acute pain management
U
3. PROVISION OF SAFE AND EFFECTIVE ACUTE PAIN MANAGEMENT
Education
N Level I
N Level I
N Level I
N Level III-1 SR
N Level III-1 SR
N Level III-1 SR
U Level II
N Level II
S Level III-2
S
Level III-2
S Level III-3
U
Organisational requirements
U Level III-3
U Level III-3
U Level III-3
N Level III-3
N.
Economic considerations in acute pain management
N
4. ANALGESIC MEDICINES

Opioids
Systemic
U Level I
U Level I
S Level I
N Level I
S Level I
N Level I
S Level I N Level II
N Level I
N Level I
S Level I
S Level I
U
Level I
U Level I
N Level I
N Level I
N Level II
U Level II
S Level II
U Level II
U Level II
U Level II
N
Level III-1
N Level III-2 SR
U Level III-2
N Level III-2
N Level III-2
U Level III-3
N Level III-3
U Level IV
S Level IV
N Level IV
S
Intrathecal
N Level I
U Level I
U Level I
Epidural
N Level I
U
Level II
S Level I
U Level II
U
Peripheral

U Level I
N Level I
S Level I
Paracetamol
U Level I
U Level I
N Level IV
N Level I
Nonselective NSAIDs and coxibs
Systemic
S Level I N
Level I N Level I
U Level I
N Level I
U Level I
S Level I
N Level I
N Level I
W Level I
U Level I
N Level I
S Level I
W Level I U Level I
U Level I N Level III-2
S Level I
U Level I
surgery.
S Level I
S Level I
U Level II
N Level I
U Level I
N Level III-2 N Level I
U Level II
N Level III-2
S
Level IV
U
N
Nonsystemic
S Level I
N Level I
U Level I
N Level I
Local anaesthetics and other membrane stabilisers
Systemic
S Level I
N Level I
U Level I
to use membrane stabilisers including systemic lignocaine in the management of acute

U
Regional local anaesthetics

U Level I
U Level I
S Level I
U Level II
U Level II
U Level II
N Level IV
N Level IV
S Level IV
U Level IV
Q
Inhalational agents
S
N S
Level I
N Level IV SR
N Level I
U
Level II
S
Level II
U
NMDA-receptor antagonists
Systemic
N Level I
S Level I
N Level I
S
Level I).
N Level I
N Level I
R Level I
S Level II
8. U Level II
N Level II
N
Regional
U Level I
N Level I
Antidepressant medicines
S Level I
S Level I
N Level I
S Level I
N Level II
in the
S
Q
Anticonvulsant medicines

S Level I
N Level I
S S U
U U Level I
Q
Alpha-2 agonists
Systemic
S Level I
Regional
S Level I) N Level I
N Level I
N Level I
S Level I
Q Level I
S Level II
W Level II
U Level II
Salmon calcitonin and bisphosphonates
Q Level I
S Level I
U Level II
S Level II
Cannabis, cannabinoids and cannabimimetics
U
Level I
U Level I
N Level I
Corticosteroids
Systemic
S Level I
N Level I
N
Level II
N
Regional
U Level I
U Level I
N Level II
U Level II
N Level II
U Level II
S Level IV
N
N
Other regional analgesic medicines
U Level I
S Level I
U Level I
U Level I
Complementary and alternative medicine

Salix alba Harpagophytum procumbens
N Level I
Arnica montana N Level I
Hypericum perforatum N Level I
Hypericum perforatum
N Level II
N Level II
U
5. ADMINISTRATION OF ANALGESIC MEDICINES
Oral route
U Level I
U Level I
U Level I
U Level II
U
U
U
Intravenous route
U Level I
an increased risk of respiratory depression compared with other methods of parenteral

U Level IV
U
Intramuscular and subcutaneous routes
U Level II
Transdermal route
should not be used in the management of acute pain because of safety concerns and
Q Level IV
S
Transmucosal routes
S Level I
N Level I N Level I
N Level I
S
Epidural analgesia
U Level I
U Level I
S Level I
S Level I
N Level I
S evel I
N Level I
N Level I
Level III-2
N Level I
U
Level I
U Level I
S Level I
‐impregnated dressings of epidural catheters in comparison to placebo‐ or
‐iodine‐ U
Level I
U Level I U Level II N
Level III-2
U
Level II
S Level IV
U
Level IV
N
Intrathecal analgesia
S Level I
S Level I
N Level I)
with intrathecal opioids in comparison to systemic opioids for minor but not major surgery
Q Level I
N
Level I
N Level I
N Level I
Q
N
U
(N).
Other regional and local analgesic techniques
U Level I
N Level I
S Level I
N Level I
S Level I
U Level I
N Level I
S Level I
U Level I
S
N Level I
N Level I
N Level I
Q Level I
N Level I
N
Level I
N Level I
Q Level II
weakness (N) Level II
N Level II
N Level IV
N
Level IV
N
Regional analgesia and concurrent anticoagulant medications
U Level IV
U
6. PATIENT-CONTROLLED ANALGESIA
U Level I
U
Level I
U Level I
U Level I
Q Level I
N Level I
(N) (Level I
incidence of respiratory depression (S) (Level I)

U Level II
U Level II
U Level II
U Level II
U Level II
N Level II
N Level III-3
N Level IV SR
S Level IV
N
7. NONPHARMACOLOGICAL TECHNIQUES
Psychological interventions
S Level I
Q Level I
S
Level I
Q Level I
Q Level I
N Level I
Q Level I
U Level I
Q Level I
U Level I
U Level III-2
Transcutaneous electrical nerve stimulation
N Level I
N Level I
N Level I
Q Level I
Acupuncture and acupressure
S Level I
N Level I
S Level I
S Level I
N Level I N
Level I
S) Level I N Level I
N Level I
N Level II
Physical therapies
N
8. SPECIFIC CLINICAL SITUATIONS
Postoperative pain
Multimodal postoperative pain management
N Level II
N
N Level I
N
Enhanced recovery after surgery
N Level I
N
Postoperative neuropathic pain
S Level IV
Treatment of acute neuropathic pain should follow guidelines for chronic neuropathic
U
Acute postamputation pain syndromes
S Level I
Q Level I
S Level I
S Level I
S Level II
U
Level III-2
U
Other postoperative pain syndromes
S Level I
S Level I
S (Level I
N Level IV
Day-stay or short-stay surgery

N Level I
N
Level I
N Level I
N Level II
S Level II
S Level II
S Level II
N Level II
N Level II
N Level II
U Level IV
U Level III-3
U Level IV
Cranial neurosurgery
S
Level I
U
Level II
U Level IV
U Level III-2
U Level IV
N
Spinal surgery
N (Level I)
N
Level I
N
Level II
N Level II
N Level II
N Level III-3
N
Acute pain following spinal cord injury
S Level I
S Level I
U
Level II
U
Acute burns injury pain
U Level I
S Level II
U
Level II
S Level II
N Level II
N Level II
U
Level III-3
U Level IV
S
Acute back pain
U Level I
U Level I
U Level I
U Level I
U Level III-2
U Level III-2
Acute musculoskeletal pain
U Level I
U
Level I
U Level I
U Level I
U Level I
U
Level I
A management plan for acute musculoskeletal pain should comprise the elements of
U
Acute medical pain
Acute abdominal pain
U Level I
U Level I
U Level I
N Level I
U Level I
S Level I
S Level I
S
Level I
N Level I
N Level II
S Level I
N Level I
N Level II
U
Level II
Herpes zoster
U Level I
S Level I
S Level I
U Level II
U Level II
U
Acute cardiac pain
U Level II
U Level IV
N
Acute pain associated with haematological disorders
S Level I
U Level I
U Level I
N Level I
S Level II
U Level II
N Level III-3).
U
Acute headache
Tension-type headache
W Level I
S Level I
N Level I
Q Level I
Migraine
S Level I
S Level I
N Level I
N Level I
N Level I
Level II
S
Level I N Level I
S Level I
N Level I
N Level I
N Level III-2
U
Level I
N Level I
U Level II
U Level II
N Level III-2 SR
N Level III-2
Cluster headache
S Level I
Postdural puncture headache
S Level I
S Level I
Level I
S Level I
Level II
U
Acute pain associated with neurological disorders
N Level I
N Level I
N Level I
Treatment of acute pain associated with neurological disorders is based largely on
Orofacial pain
Acute dental pain
N Level I
N Level I
Dental extraction
S Level I
N Level I
N Level II
N Level I

N Level I
N Level I
N Level I
U Level I
U Level II
Tonsillectomy
N Level I
N Level II
U Level I U Level II
U
Level I
S Level I
R Level I
U Level I
N Level I
N Level II
U Level II
Pharyngitis
S Level I N Level I
U Level I
N Level I) N Level II
U Level II
Sinusitis
N Level I
N Level I
Oral mucositis
U Level I
U Level I U Level I
N Level II N Level II
U Level II
N
S
Acute pain in patients with HIV infection
(S) Level I
(S) Level I .
R
Level I
U Level III-2
S Level IV
U
Acute cancer pain
S Level I
S Level I
N Level I
N
Level I
S Level II
U Level III
N Level IV SR
U
Prompt assessment and fast coordinated management of spinal metastases with
N
s
S
U
l
N

N
Acute pain management in intensive care
R Level I
W Level I
N Level I
N)
Level II
U Level II
U Level III-1
N Level III-
1
N Level III-2
N
Acute pain management in emergency departments
N Level I
Abdominal pain
U Level I
Migraine (see also Section 8.6.5)
S Level I
Fractured neck of femur
N Level I
U Level II
li
Local anaesthesia
N Level I
U Level I
U Level II
wound care in the emergency department.
U
Prehospital analgesia
N Level II
S Level II
S Level II
S Level II
N Level III-3
U Level IV
N Level IV
U
Discharge medication for acute pain management
N Level III-2
N Level III-2
N
Level III-2
N
Level III-2
N Level III-3
lii
9. THE PAEDIATRIC PATIENT

Consequences of early pain and injury
S Level III-2
N Level III-2
N Level III-2
Paediatric pain assessment
S Level IV
S Level IV
Pain assessment and measurement are important components of paediatric pain
U
Q
Analgesic agents
Paracetamol
S Level I
N Level IV
SR
N
Nonselective NSAIDs
S Level I
S Level I
N Level I
S Level II
N Level III-3
U
liii
Coxibs
N
Opioids
S Level II
S Level IV
N Level IV
N Level IV
N
Tramadol
N Level II).
N
Ketamine
N Level I
N
Level I
N Level I
N Level II
N
Alpha-2-delta ligands (gabapentin/pregabalin)

(N) (Level I
(N) Level I
N Level I
N Level II
N
Corticosteroids
S Level I
Q Level I
N Level I
Opioid infusions and PCA
Q Level I
N Level III-3
U Level II
U Level III-1
S Level III-3
S Level III-2
N Level III-2
N Level III-3
W
Regional analgesia
U Level I
U Level I
N Level I
N Level I
N Level
S
Level I U Level II
N Level I
N Level II
U Level II
U Level II
N Level III-3 SR
U Level II
U Level II
S Level III-2
S Level III-2
S Level IV
N Level III-2
N Level IV
N Level IV
S Level IV
Management of procedural pain in children
S Level I
S Level I
N Level I
N Level I
N Level II
N Level I
U Level I
S Level I
S Level I
Q Level I
S
Level I
N Level I
U Level II
N Level II
N Level II
N Level III-2
N Level III-2
N Level IV
N
Acute pain in children with cancer
S Level I
N Level I
U Level II
N Level II
N
N
Paediatric migraine
N Level I
N Level I
N
10. OTHER SPECIFIC PATIENT GROUPS
The pregnant patient
Use of analgesics in pregnancy
N Level I
N Level III-2 SR
W Level III-2
N Level III-3 SR
nd
U
Painful conditions in pregnancy
N
Level I
N Level IV SR
Neuraxial and regional analgesia
S
N Level I
N Level II
N

Q U
U U Level I
N Level I
N Level I
U U
Q Level I
N Level I
U
U Level I
N Level I
U Level I
U Level I
Systemic analgesia
N Level I
S
N S
Level I
N Level IV SR
N Level I
N
N
N
W Level I
N Level I N Level II
N Level I
Complementary and other methods of pain relief in labour
S Level I
N Level I
N Level I
S Level I
N Level I
Q Level I
R N N
N Level I
Pain relief after Caesarean delivery
S Level I
N Level I
Level I
N Level I N Level I
N Level II
N Level I
N
Lactation
S Level IV
S
Level IV
S Level IV
U
Pain in the perineum
U Level I
episiotomy or second-degree tears reduces perineal pain and analgesic use in the
N Level I
S Level I

Q Level I
U Level I
U
Level I
W Level I
U
U
The older patient
S Level I
S Level I
U Level II
N Level III-2 SR
W Level III-2 SR
U Level III-2
S Level III-2
U
Level III-2
Q Level III-2
S Level III-2
U Level IV
S
Level IV
U
Culturally responsive care for Culturally and Linguistically Diverse patients
N Level III-3
Cultural competence of health professionals supported by cultural competency training
N
N
Aboriginal and Torres Strait Islander peoples
U Level III-3
U
Level IV
N Level III-2
N Level III-2
N
N
The patient with sleep-disordered breathing including obstructive sleep apnoea
S Level III-2 SR
N
Level III-2
Q Level III‐2
S Level III‐2
U Level III‐2
N Level III‐3
N
N
N
The patient with concurrent renal or hepatic disease
U
The opioid-tolerant patient
N
Level I
N
N Level I N Level I N
Level II
N Level II
S Level II
N evel II
U
N
U Level III-2
N Level III-2
S
N
N
The patient with an addiction
N Level I
N Level III-2
S Level III-2
N
U
U
1. PHYSIOLOGY AND PSYCHOLOGY OF ACUTE PAIN
1:
PHYSIOLOGY AND PSYCHOLOGY OF ACUTE PAIN
1.1 Applied physiology of acute pain
GL
NR
NR NR NR
encouraged.
1.1.2 Nociceptive pathways and pain perception
NR
NR NR
1.1.2.1 Peripheral nociceptors
NR NR
NR
NR
NR
other ion channels that include ligand-gated channels such as acid-sensing ion channels
NR
NR
NR
NR
Nociceptor plasticity
NR
primary hyperalgesia
NR NR
NR
NR
NR
NR NR
NR
NR
1:
NR
Ligand
acid sensing
glutamate glutamate
purine ATP
serotonin
acetylcholine
Ligand
metabotropic glutamate glutamate
prostanoids
IP
histamine
serotonin
bradykinin BI
cannabinoid CB anandamide
tachykinin
proteinase protease
tyrosine kinase receptor
opioid
Notes: Immune mediators including cytokines such as TNF alpha, interleukin B and CCL3 can also act
5-HT: serotonin; ASIC: acid sensing ion channel; ATP: adenosine triphosphate; BK: bradykinin;
NK1: neurokinin-1; P2X3
2 2
; PGI2 1
,
14
NR NR
NR
NR
NR NR
1.1.2.2 Nociceptive transmission in the spinal cord
NR
NR
NR
This mechanism has been implicated in learning and memory in the hippocampus and
NR
NR
1:
NR NR NR

NR
same cellular mechanisms but are independent phenomena.
NR NR
NR
NR
1.1.2.3 Central projections of nociceptive pathways
NR
Craig
NR
NR NR NR
NR
spinal cord.
NR
NR NR
of the amygdala; DRG: dorsal root ganglion; Hip: hippocampus; ic: internal capsule; LC: locus
coeruleus; PAG: periaqueductal grey; PB: parabrachial area; Po: posterior group of thalamic
nuclei; Py: pyramidal tract; RVM: rostroventromedial medulla; V: ventricle; VMH: ventral
medial nucleus of the hypothalamus; VPL: ventral posterolateral nucleus of the thalamus;
VPM: ventral posteromedial nucleus of the thalamus
Source:
1:
1.1.2.4 Descending modulatory pathways

NR
NR
NR
NR NR). Serotonergic and noradrenergic pathways in the dorsolateral
NR
NR
NR
NR NR
NR NR NR
1.1.3 Physiological and pathological pain
NR
NR
7
NR
NR
pain can also present acutely following trauma and surgery. The incidence has been
Level IV
NR
NR
NR
NR NR
NR NR
NR NR
1.2 Psychological aspects of acute pain
NR
NR Level IV NR
NR
8
1:
NR
NR
NR
1.2.1 Psychological factors
NR
1.2.1.1 Attention
NR
NR
Level IV SR
1.2.1.2 Learning processes
NR Level III-2
NR
1.2.1.3 Beliefs and thought processes
NR
9
Level IV
Level IV Level IV with higher

pain scores Level IV
Level IV
Level IV
Level IV
catastrophising.
Theunissen
Level III-2 SR
Level IV SR
Level III-2 SR
Level I
Level III-2
1.2.1.4 Depression and anxiety
impact of both acute and chronic pain.
Level IV SR
Level IV SR
Level IV SR
Level IV
1:
Level IV
NR
1.2.1.5 Conclusions
1.2.2 Patient-controlled analgesia
Level IV Level IV Level III-1 Level IV

Level IV Level IV Level IV
Level IV
Level IV Level IV
Level IV Level IV
Level IV Level IV
Level IV
Level IV
Level IV Level IV
Key messages
N Level I
N Level III-2 SR
N Level IV SR)
N Level III-2 SR
S Level IV SR S Level IV SR
U Level IV
U Level IV
opinion.
(U).
1.3 Placebo and nocebo effects in acute pain
NR
Level I
NR
NR
NR NR
•
Petersen
Level I
1:
1.3.1 Mechanisms
topic area.
1.3.1.1 Psychological mechanisms
NR
Expectancy
NR
Level II
Level II Voudouris
Level III-1
Level II Level II Level II
NR
Level III-3 EH
•
•
•
Level II EH
response is large.
Classical conditioning
NR
BS Level II EH
Level III-1 EH
Level III-2 EH
Level III-1 EH
Level II EH
1.3.1.2 Neurobiological mechanisms
NR
Level II EH Level II EH
Level II EH
NR
Level II EH
this nonopioid-mediated placebo analgesia was found to be the endogenous cannabinoid

Level III-1 EH
Level III-2 EH
Level III-3 EH Level III-2 EH

Level III-1 EH
although much more research is needed in this area.
Level IV SR EH
Level I
1:
Level I
Level I
Level I
1.3.1.4 Clinical implications
NR
NR
present.
NR NR
NR
this are listed below.
•
•
•
•
•
•
To enhance learning components:
•
•
•
•
Key messages
N Level I
N
Level I
N Level I
N Level II
N Level III-1
N Level II
N
Level II
opinion.
1.4 Progression of acute to chronic pain
Level IV
NR
NR NR
NR NR Level IV Level II
1.4.1 Epidemiology of chronic postsurgical pain
Level IV
Level IV
1:
NR NR Level IV
Level IV
Level IV
Level IV
Thoracotomy
Inguinal hernia
Coronary bypass
Cholecystectomy
Vasectomy
1.4.2 Characteristics of chronic postsurgical pain
NR)
NR
Level IV GL
Level IV
Level IV
Level IV
Level IV
Level IV
Level III-1
Level IV
NR
chronic pain and along with psychological distress may include the need for strong analgesic
Level III-1 NR
1.4.3 Predictive factors for chronic postsurgical pain
Level IV SR
Level IV SR
Level IV ” was the main risk factor for the

Level IV
Level III-2
Level IV
Level II
Level IV Level IV
Level IV Level IV Nikolajsen
Level IV Level IV
Level IV Level IV
Level IV
NR
Level IV Level IV
Level IV Level IV
Level IV
Level IV
Level I
1:
Level IV

Level IV
Level IV
Level IV
NR NR
Level IV
Level IV
NR
Level IV
1.4.4 Mechanisms for the progression from acute to chronic pain
NR
NR
NR
NR
Level IV
Level II
Level II
Level IV
Level IV SR
1.4.5 Prevention of chronic postsurgical pain
NR
1.4.5.1 Regional or neuraxial analgesia
Level I
Level I
Level II
Level III-2
Level III-2
1:
Level III-2

Level III-2 SR
Level II
Level II
Level II
Level I
Level II
1.4.5.2 Pharmacotherapy
Level I
Level I
Level I
Level I
Chaparro
Level I
Level II
Level II
Level II
Level III-2
Level III-2
Level III-3
GL
Level I
Level I
1.4.5.4 Multidisciplinary approaches
Level IV
Key messages
S Level I
N Level I
S Level I
N Level I
S Level I
N Level III-2 SR
N Level IV SR
S Level IV SR
8. Spinal anaesthesia in comparison to general anaesthesia reduces the risk of chronic
U Level III-2
S Level IV
S Level IV
1:
opinion.

N
1.5 Pre-emptive and preventive analgesia
NR
BS
NR
NR NR
NR
NR
NR
NR NR
Sources: Moiniche 2002; Katz 2002; Katz 2011

1.5.1 Pre-emptive analgesia
NR
Level I Level I
Level I
NR
NR
Level I
1.5.2 Preventive analgesia
Level I
NR
Level I
Level I
Level I
Level I
1:
Level II
Key messages
U Level I
S Level I
S Level I
S Level I
opinion.
1.6 Adverse physiological and psychological effects of acute pain

1.6.1 Acute pain and the injury response
EH
Level IV EH SR
n
Level II
NR NR Level II
Level IV EH SR
Level II
Vigneault
Level I Level I
Level II
NR
NR NR NR
Triggers and predisposing
Surgical trauma or injury Neural

primary and secondary
Immune factors
Proteins and other
molecules:
• growth factors
• ecosanoids
• others
Psychological factors Catabolism
factors
systemic
1:
1.6.2 Adverse physiological effects

NR NR
NR
NR NR
Endocrine Catabolic hormones A
Anabolic hormones
compensatory response Chemokines
Carbohydrate
insulin resistance
Protein
synthesis of acute phase proteins
Lipid
growth hormone
other factors
1.6.3 Pain and analgesia: effects on injury-induced organ dysfunction

NR
NR NR
metabolism and accelerated protein breakdown also contribute to the injury response. These
NR
Popping
Level I
NR NR
Key messages
S
Level I
opinion.
U
1.6.4 Adverse psychological effects
Cousins
NR
NR Level III-2
Level III-2
Level IV SR Level III-3

NR
NR
NR NR
1.7 Genetics and acute pain
Trescot
1:
NR
NR NR

NR
NR Lotsch
NR NR
NR NR
NR
1.7.1 Single gene pain disorders
following.
• SCN9A
Na
NR
SCN9A
Level III-2
• are associated with
NTRK1 NR
NR
NR
•
SCN9A
NR
•
•
• NR
Level IV Twin studies
NR
BS
NR
NR
commonly studied genes include:
• OPRM1
• COMT
•
• TRPV1
• MC1R
states include ADRB2, HTR2A, IL1RN, KCNJ6, MAOA and MAOB NR

1.7.2.1 OPRM1
NR
NR
OPRM1
OPRM1
Level III-2 SR
OPRM1 with increased

Level III-2
SR OPRM1 with opioid
OPRM1
Level III-2 SR OPRM1
Level III-2
Level III-2
OPRM1
of the OPRM1 OPRM1

Level III-2 NR
OPRM1
NR
1.7.2.2 COMT
Nackley
NR
NR
NR
Level IV Level IV
1:
COMT

with any COMT
Level III-2 COMT
Level III-2 COMT

NR
1.7.2.3 TRPA1
Level III-2
1.7.3 Drug metabolism
NR
NR
Level III-2
The CYP2D6
NR
CYP2D6
NR NR
NR NR CYP2D6
NR NR NR
NR NR NR
NR
NR Level IV
Level III-2
Level III-2
Level III-2
NR
Level IV; Level III-3
1.7.3.1 Codeine
Level IV
Level IV Level II
CYP2D6
Level IV
Level IV
Level IV Level IV
1.7.3.2 Tramadol
NR
Level III-3 Level II

Level IV Level III-3 Level III-3
Level II ; CR
1.7.3.3 Methadone
NR NR
NR
CYP2B6
NR
polymorphisms in CYP2C19
NR
1.7.3.4 Oxycodone
NR
EH
EH
NR
EH
NR EH
1:
CYP2D6
Level III-2

Level III-2
NR
1.7.3.5 NSAIDs
PTGS2
NR Level III-2
NR
CYP2C9*3
Level IV Level III-3 NR
NR
Key messages
Q Level II
N Level III-2
N
Level IV
opinion.
References
Pain 137
Anesthesiology 112
J Pediatr Surg 42
Acta Anaesthesiol Scand 54
Br J Pharmacol 164
Hernia 15
Ann Surg
243
acute pain management. Minerva Anestesiol 76
surgical pain. 16
J Neurosci 19
on acute and chronic postmastectomy pain. Clin J Pain 26

Paediatr Anaesth 24
Br J Anaesth 111
Spine J 14
520
225
Handb Clin Neurol 115
Behav Pharmacol 22
Ann Neurol
74
Anesth Analg 116

Cell 139
Anesth Analg 109

JAMA 159
47
Nat
Commun 5
Annu Rev
Pharmacol Toxicol 48
346
receptors. Nat Med 17
Neuroscience 147
Lancet Neurol 13
Pain 120
Sci Transl Med 3
Hernia 16
Surg Clin North Am 91
Anesthesiology 102
J
Cardiothorac Vasc Anesth 19
analgesia for abdominal surgery. Pain Pract 14

Physiol Rev 94
analgesia. Acute Pain 4
Anesthesiology 106
treatment. 10
Ann Intern Med 97
Pain 155
Pain Med 13
AAPS J 11
Nat
Rev Neurosci 14
Int J Immunopathol
Pharmacol 24
Neural Blockade
in Clinical Anesthesia and Pain Medicine
Pain 154
Prog Brain Res 169:
Pain 152
adults. Cochrane Database Syst Rev 7

Anesth Analg 116
1:
Anesth Analg 115

Anesth Analg 116
J Psychosom Res 58
Pain 124
Pain 144
Minerva Anestesiol 71
Br J Anaesth
109
Annu Rev Neurosci 32

Pain 112
Annu Rev Neurosci 26:
Nat Rev Neurosci 10
Clin Pharmacol Ther 95
Pharmacol Biochem Behav 123
Pain 154
a chronic pain clinic. Pain 76
mechanisms of pain. Pain 131

Br J Anaesth 101
Curr Neurol
Neurosci Rep 12
Br Med Bull 71
Spine J 10
Clin J Pain 24
Nat Neurosci 17
tramadol. Br J Clin Pharmacol 41
Hum Mol Genet 14
Pain Med 11
J Pain 15
Anesthesiology 118
J Clin Invest 120
pain. Psychol Bull 125

Brain
135
placebo analgesia. Neuron 63

Prog
Neurobiol 109
Science 196
Br J Anaesth 110
20
Cousins and
Bridenbaugh’s Neural Blockade in Clinical Anaesthesia and Pain Medicine
Lancet
375
J Gerontol
A Biol Sci Med Sci 54
Pharmacol 61
Curr Opin Psychiatry
25
Am Psychol 69
Pain 95
dosing guidelines: three case reports. J Opioid Manag 9
children. Pharmacogenomics 14
Chest 128
Schmerz 17
Clin J Pain 8
psychological factors to pain and analgesic use. Clin J Pain 6
Br J Anaesth 111
Nat Med 16
Clin J Pain 21
Anesthesiology 95
Clin J Pain 28
J Pain 8
J Neurophysiol 97
Acute Pain
4
Brain Res Rev 60
13
Pain Med 10
Cochrane Database Syst Rev
Anesthesiology 103
19
Nat Rev Neurosci 2
Anesthesiology 121
IASP Taxonomy by Task Force on Taxonomy
Anesthesiology 111
following breast cancer surgery. J Behav Med 19
Anesth Analg 77
J Psychosom Res 66
Pain 152
Pain
Brain Res Rev 60
Paediatr
Anaesth 22
Pain 155
1:
and predictors in the Tromsø study. Pain 153

chronic pain. Pain 107
Anesthesiology
119
Crit Rev Clin Lab Sci 48
Anesthesiology 114
Can J Anaesth 55
Clinical
Pain Management: Acute Pain
Arnold.
Anesth Analg 113
pain. Clin J Pain 12

Lancet 367
Pediatrics 129
and neurobiological underpinnings. PLoS One 9
research. J Pain 10
Pharmacogenomics J 7
13
Anesth Analg 79
Pain 155
Mol Pain 9
Nat Med 16
J Pain 5
Br J Anaesth 97
Pain 152
analgesia. Can J Anaesth 58
Pain Med 12
Anesthesiology 103
J Behav Med 30
Neurophysiol Clin 42
Lancet 2
Br J Anaesth 114
Mol Diagn Ther 12

Neural Blockade in Clinical Anesthesia and Pain
Medicine
Pain 121
placebo trial design. PLoS One 9

Br J Anaesth 101
Am J Surg 195
Pain 153
on the surgical model? A comparison of total knee arthroplasty and breast surgery for cancer. J Pain 14
Curr Opin Anaesthesiol

27
Best Pract Res Clin

Anaesthesiol 28
J R Soc Med 101
Ann Intern
Med 136
Trends Genet 28
Anesthesiology 96
Anesthesiology 108
general analgesia. Ann Surg Oncol 18
from bench to bedside? J Pain Res 6
Pain 128
Anesthesiology 106
Phys Ther 91

Acta Anaesthesiol Scand
48
study. Brain 130

J Physiol 554
management: a meta-analysis. Anesth Analg 100

J Clin Invest 120
Brain Behav Immun 20
postsurgical pain: a longitudinal study. J Pain Res 6
J Pain Res 6
1:
Nat Rev
Drug Discov 8
Clin J Pain 21

Clin J Pain 10
Br J Clin Pharmacol
39
Pain
155
295
BMC Musculoskelet Disord 15
Pain 153
93
Ann Surg 259
54
Best Pract Res Clin

Anaesthesiol 28
Nat
Neurosci 17
288
thought. Annu Rev Psychol 59
83
Pain Med 9
Dig Liver Dis 44
Pain 130
Mol Interv 8
Curr Drug Metab 15
for total knee arthroplasty. Pain Res Manag 12
58
management in children. Pharmacogenomics 15
Br J Pharmacol 160
Physiol Rev 89
437
Br J Anaesth 103
Anaesth Intensive Care 28
Anesth Analg
99
Pain Med 15
Neuron 77
Br J Cancer 107
Hernia 14
Pain 155
Drugs 73
Clin J
Pain 26
Pharmacogenomics 15
labor: a meta-analysis. Genet Test Mol Biomarkers 17
Pain 105

8
Anesth Analg 107
PLoS One 8
Brain Res Rev 60
J Pain 8
Dis Colon Rectum 55

Crit Care Clin
24
Clin J Pain 28
analgesia. Br J Anaesth 74
Anesth Analg 104

Nat Rev Neurosci 11
Br J Anaesth 101
Neuron 55
Pain 156
Best Pract Res Clin Anaesthesiol 28
Psychological Aproaches to Pain

Management
epidemiological studies. Pain 155
Reg Anesth Pain Med 37
to establish core risk factor and outcome domains for epidemiological studies. Clin J Pain 29
Brain Res Brain Res
Rev 46
Pain 145
placebo analgesia. 99
105
morphine in children. Pharmacogenomics 15
Pain 105
1:
pain and parental judgment of their child’s pain. Pain 142

Can J Anaesth 58
mechanisms. Neuron 73
Pain 38
Pain 43
Pharmgenomics
Pers Med 5
Pain 33
Pharmacogenomics 14
OMICS 17
Neuron 78
for breast cancer: meta-analysis of randomised controlled trials. Breast 23
Nat Neurosci 17
Br J Anaesth
113
Anesthesiology 112
Spine J 14
Spine J 14
Anesth Analg 108
Anesth Analg 112
Front Neurosci 7
thoracic surgery lobectomy. Br J Anaesth 108
Br J Anaesth 89
J Orthop Trauma 23
Int J Obstet Anesth

19
Pain 152
Nature 306
J Clin Invest 120
widespread pain? Pain 155

Neuron 55
Pain 152
19
21
Pain Med 13
Pain 138
African American children with sickle cell disease. J Pediatr Hematol Oncol 35
Pain 134
Br J Anaesth
106
Clin Pharmacokinet
48
Clin
Pharmacokinet 48
receptors. J Neurosci 25

2. ASSESSMENT AND MEASUREMENT OF PAIN AND
2:
PAIN TREATMENT
ASSESSMENT AND MEASUREMENT OF PAIN AND PAIN TREATMENT

management. The assessment and measurement of pain are fundamental to the process of
response. Pain should be assessed within a biopsychosocial model that recognises that
Level IV Level IV
2.1 Assessment
The assessment of acute pain should include a thorough general medical history and
NR
GL
Level III-2
NR
Level IV
NR Level III-2
GL
•
•
•
• the presence of dysaesthesias

hyperalgesia
and
•
phenomena.
GL
GL NR
NR
NR
including details of trauma or surgical procedures
a at rest
c health professionals consulted
a belief concerning the causes of pain
Leeds
2:
2.2 Measurement

NR
NR
In these circumstances other methods of pain assessment will be needed.
post hoc NR
GL
Level III-3
GL
NR
2.2.1 Unidimensional measures of pain
NR NR
2.2.1.1 Categorical scales
Categorical scales use words to describe the magnitude of pain or the degree of pain relief
NR
Level III-2
Level IV
Level III-2
2.2.1.2 Numerical rating scales
NR
NR
Level IV
Visual analogue scales
Level III-2
Level IV Level IV
Level IV
Level IV Level IV
Level IV Level IV
Level IV
NR
NR
to moderate intensity Level IV Level IV
Level IV SR
n unspecified
Level III-2
2.2.2 Functional impact of acute pain
NR
2:
NR
scores.
2.2.3 Multidimensional measures of pain
Level IV
NR
Neuropathic pain
GL
Level IV Level IV
Level III-2 NR Level III-2
Level IV Level III-2
Level IV
•
Level III-2 NR
•
Level III-3
•
Level III-3
•
NR
• Level IV
GL
NR
Level IV
Level III-2
2.2.4 Patients with special needs
Level III-3
Level III-3
Level III-3 Level III-3
Level III-3
Key messages
U Level III-3
S Level IV SR
N Level IV
opinion.
U
2:
2.3 Outcome measures in acute pain management

NR
GL
2.3.1 Outcome measures
2.3.1.1 Pain
Level I
NR
•
-
relief
-
-
•
-
-
•
-
-
-
NR
NR
Level I
Level I
2.3.1.2 Physical functioning
NR
NR
• disability scales
NR
•
than for cancer-related pain NR
Level IV
Patrick
NR
2.3.1.3 Emotional functioning
2.3.1.4 Adverse effects
Level I Level I
Level II
Level IV Level IV NR
2:
Key message

opinion.
References
Anesthesiology 98
Clin J Pain 19
11
postsurgical pain. Pain 107
Crit Care Med 41

Pain 92
343
Pain 114
Pain 108
Clin J Pain 16
Br J Anaesth 101
Anesthesiology 106
J Pain Symptom Manage 25
Pain 105
report intensity scales. Pain 151
assessment good enough? Pain 91

Int J Geriatr
Psychiatry 14
11
cancer and other diseases. Pain 17
neuropathic pain. J Pain 8
Pain 153
Intensive Crit Care Nurs 30

Int J Qual Health Care
16
Pain 88
Pain 94
Curr Med Res Opin 22

Neurophysiol Clin 42
low back pain. Spine 26
Semin Respir Crit Care Med 34
Arch Intern Med 165

management. BMJ 305
Pain 152
Pain 152
J Pain
Symptom Manage 41
JAMA 285
Pain 99
J Pain 4
Pain 137
J Pain 6
Pain 110
Pain 152
Clin J Pain 19
control. 10
period. Anaesthesia 64
anyway? J Pain Symptom Manage 25
Br J Anaesth 101
Pain 30
Anesth Analg 89
Anaesth
Intensive Care 33
Med Care 27
Curr Med Res
Opin 22
J Crit Care 30
Clinical Pain Management: Acute Pain
J Clin Nurs 21
Int J Nurs Stud 49
Assessment Scale. Clin J Pain 24
Lancet 372
research. Can J Anaesth 55

Textbook of Pain
Anesthesiology
95
3. PROVISION OF SAFE AND EFFECTIVE ACUTE PAIN
3:
MANAGEMENT
PROVISION OF SAFE AND EFFECTIVE ACUTE PAIN MANAGEMENT

and psychologists.
NR
3.1 Education
3.1.1 Patients
Counsell
NR NR
Level IV
Level IV
3.1.1.1 General principles
Level IV SR
ad hoc. Verbal teaching and discussions were found

unstructured ad hoc teaching.
NR
Level I
Level III-3 SR
Level III-2 SR
Level III-2 SR
Level III-3 SR
Level II
Level III-2
Level III-1
3:
PCA use
Level III-1 SR
Arthroplasty
Level I
Level III-1
SR
Cardiac surgery
Level I
Other types of surgery
Level II
Level III-1
Level II
prepared for surgery.

3.1.1.3 Effects in other acute pain settings
Level I
Level I
Level III-1 SR
Level III-1 SR
Level III-1 SR
Antenatal teaching about postnatal nipple pain and trauma resulted in reduced nipple pain
Level II
Level IV
3.1.1.4 Web-based education for acute pain management
Level I
Level II
Level II
Level II
Level II
3.1.2 Staff
NR
Level III-3
3:
Level III-2

Level III-3

Level III-3
Level III-2
Level III-3

Level III-3 Level III-2 Level II
Level III-3
Level III-3
Level III-3
Level III-3 SR
Good Prescribing Guide
Level III-3 Level IV
Level IV
Level III-3
Level III-2
NR
Level II
that this type of teaching may need to be incorporated at an earlier stage of learning or by
NR
Key messages
N Level I
N Level I
N Level I
N Level III-1 SR
N Level III-1 SR
N Level III-1 SR
U Level II
N Level II
S Level III-2
S Level III-2
S Level III-3
opinion.
3.2 Organisational requirements
GL
GL
NR
Level III-3
NR
NR
analgesia.
3:
3.2.1 General requirements

NR NR
NR
Level III-3
Level III-3
Level IV Level IV
Level IV
Level IV
NR
NR
GL GL GL GL
NR NR
3.2.2 Acute pain services
NR
Level IV NR
NR NR
NR
NR
and use protocols Level IV
Level II
Nagi
NR
Level IV
Level IV
Level IV
Level IV
Level IV
NR
NR NR
Level III-3 Level III-3 Level IV

Level III-3 Level III-3 Level III-3 Level III-3
Level IV Level III-3 Level IV
Level III-3
Level IV
Level III-3 SR Level III-3 SR
ways.
Level III-2
NR
3:
3.2.2.1 Safety

Level III-3 NR
Level III-2
Level III-3
References
surgery
Key messages
U Level III-3
U Level III-3
U Level III-3
N Level III-3
opinion.
N.
3.3 Economic considerations in acute pain management
NR
NR
NR
GL NR
analysis
analysis
NR NR NR
NR
Level IV
NR
NR
pro re nata
3:
NR
3.3.1 Economic evaluation of patient-controlled analgesia
Level III-3
Level IV
3.3.2 Economic evaluation of acute pain services
Level IV SR,
Level II
Level III-3
Level I
Level III-3
Key messages
opinion.
N
References
Pain Manag Nurs 16
Reprod Biol 177

3:
34
Anesthesiology 116
Anesth Analg 96
Headache 54
and the United States
Pain 152
Pain 143
25
J Clin Anesth 10
Clinical Pain
Arnold.
J Adv Nurs 30
50
Psychol Health Med

18
BMJ 337
Med J Aust 190
Midwifery 13
28
Int J Qual Health Care
16
Schmerz 28
Med Care 39
Can J Anaesth 61
Clin Nurs Res 19
26
Pain 83
Schmerz 17
Anesthesiology 118
Harvard
Business Review.
Proceedings of the AMIA Symposium :
Jt Comm J Qual Improv 26
34
management. BMJ 305

Cochrane Database Syst Rev 3
J Clin Nurs 24
Pain Manag Nurs 7

Anaesthesia 56
Anaesthesia 53
Anaesthesia 52
Pharmacoeconomics 31
J Clin Anesth 13
Int J Nurs Stud 51

Ann Behav Med
15
program. 17
Anesthesiology 118
Qual Saf Health Care 14
31
Outcomes
Manag Nurs Pract 3
Anesth Analg 106

Paediatr Anaesth 22
Appalachian area. J Adv Nurs 23

28
Clin J
Pain 23
Anesth Analg 111
Can Nurse 103
Physiother Theory Pract 29
39
Anaesth Intensive
Care 39
Med J Aust 153
Neural Blockade in Clinical

Anesthesia and Pain Medicine
J Med Internet Res 14
Med J Aust 170

Cochrane Database
Syst Rev 5
J Adv Nurs 41
CMAJ 168
Pain Physician 15
3:
errors. Hosp Pharm 44

management. Pain 80
Acute Pain 5
hospitals. Pain Res Treat 2011

.

AORN J 87
thoracotomy pain. Can J Anaesth 46

Br J Nurs 16
Br J Nurs 16
Phys Ther 91
database analysis and literature assessment. Clinicoecon Outcomes Res 6
Anesthesiology 120
Ann Surg 259
J R Soc Med 102
Fam Pract 31
Br J Surg 91
Anesthesiol Clin North America
23
Med Care 39
Anesthesiology 68
and assessment process. J Clin Nurs 10
BMJ 321
ANZCA
17
10
Anesth Analg 84
Br J Clin Pharmacol 67
4
Anaesth
Intensive Care 27
J Clin Nurs 21
104
hospital. Aust N Z J Surg 63

Pain
55
Anesth Analg 94
J Clin Anesth 16
Gastroenterol
Nurs 34
Anesth Analg 85
J Clin Anesth 16
Anaesthesia 61
pain. Hawaii J Med Public Health 72

Anesth Analg 111
JAMA Intern Med 175
J Gen Intern Med 17
Br J Anaesth 110
Pain Pract 12
Pain Pract 15
Anesth Analg 101
Anesth Analg 95
Anesthesiology 112
Anesth Analg 104
J Adv Perioperat Care 3

4. ANALGESIC MEDICINES
4:
ANALGESIC MEDICINES
4.1 Opioids
the periphery.
4.1.1 Systemic opioids
acute pain.
4.1.1.1 Choice of systemic opioid
NR
NR
NR
NR
Level II
Quigley
Level IV SR Level III-2 SR
aspects of selected opioid agents including tramadol.

Buprenorphine
NR
NR
Level III-3
NR
NR Selden
Level IV
NR
Level III-2 NR
NR
Level IV Level IV
NR
Level IV
Level II EH
NR
NR
NR
Codeine
NR
NR
NR
NR Level III-2
Level IV
NR
NR
Level IV
codeine
Level III-2
Level IV
Level III-2
in children
Level IV NR Level IV
4:
ANALGESIC MEDICINES
GL
NR
Dextropropoxyphene
Level I
Level I
NR
NR
NR
Diamorphine
NR
diamorphine and morphine in terms of

Level II
Level II
Level II
Level IV
Level IV
Dihydrocodeine
NR
NR
Fentanyl
NR
NR
Hydromorphone
as morphine. The main metabolite of
NR NR NR
Level I
Level I
Methadone
NR
NR
NR
NR
NR
Hypericum
perforatum
NR
Morphine
NR . It contributes to such
NR
NR
NR
NR .
4:
Level II
ANALGESIC MEDICINES
Level II Level II
Level II
Level II
Level IV
NR
Level II
Level II Level II
Level III-1 EH
Level IV
Level IV
Oxycodone
PK
Level II EH
NR NR
Level II EH
Level III-3 GL
Level II EH
PK
NR
Level II
NR
NR
Pethidine
Level II Level II
NR
Level III-2 SR
Level IV
NR NR
Remifentanil
NR
NR
Tapentadol
NR
NR
PK
Level II
Level II
NR Level II
Level I
Level II post hoc
CR
CR .
Level IV
Level III-2
Level III-2
4:
Tramadol
ANALGESIC MEDICINES
NR
Level III-1
Level I
Level I
Level II
Level III-1
NR
Level III-2
Level II EH receptors by
Level II
Level II
NR
Level II
Level II Level II EH
Level II EH
Level IV
CR
NR
Level IV
Level IV

Level II
NR Level II
Level I

Level IV Level IV
Level IV
GL
noncontrolled drug in most countries.
4.1.1.3 Determinants of opioid dose
Level IV
Patient age

Level IV Level IV
Level IV Level IV
Gender
NR
Level IV SR
n
Level IV SR
Level IV
Level I
NR
NR NR
Genetics
Psychological factors
4:
4.1.1.4 Adverse effects of opioids
ANALGESIC MEDICINES
Level I
Level IV SR
Level IV SR
Level I
Level IV
Level II
NR Level III-2 NR
Level III-2
Level III-2
Opioid-induced ventilatory impairment
respiratory depression NR
NR
Level IV
Level IV Level IV
77
Level IV
NR NR NR
Level III-3
Level III-3
NR
Level IV
GL
GL
GL
Level IV
SR
Level IV SR
78
4:
Voscopoulos
Level IV
ANALGESIC MEDICINES
NR NR
Cardiac effects
NR
Level IV NR
NR
NR
Level II
NR
Level I
NR
Level III-2
Nausea and vomiting
Level I Level IV
Level
IV SR
NR
Level I
Level I Level I
n unspecified ketamine Level I
Level I Level I
Level I
Level I
Level I
79
Level I
Level I
Level I
Level I
Level I
Level I Level I
Level I Level I
NR
Level II
Level II
Level II
Level II
Level II
-receptor antagonist or
Level I
Level I
Level II
Level II Level II
Level II
Level II
NR
Level II
Level II
Level III-3
4:
Level III-3
ANALGESIC MEDICINES
NR
NR
Level I
Level II
Level II
Level II Level II
Level II
Level II
Level II
Level II
NR
Level III-3
CR
Level I
GL
Level I
Level I
Level I
GL
Impairment of gastrointestinal motility

NR
NR
Level IV
factor for prolonged hospital stay.
Level I
NR
Level II
Chey
Level II
Level II
NR
Level II
Level II EH
Urinary retention
Level III-1
Tiippana
Level I
Pruritus
The mechanism of opioid-induced
NR
Level I
NR
Cognitive function and confusion
Level II
Level IV
Level II
Level II Level II
Level II
Level IV
Level III-2 SR
4:
Tolerance and hyperalgesia
ANALGESIC MEDICINES
NR NR
NR NR
NR NR
NR
NR NR NR
NR
NR
Level IV SR
Level I
NR
NR
NR
Level IV
Chu
Level III-2
Level III-2
Level III-1
Level III-2
Level III-2
Level I
NR
NR
Level II
Level I
Level I
Level II EH
BS
NR NR
NR
Tolerance to adverse effects of opioids
NR
Key messages
U Level I
U Level I
S Level I
N Level I
S Level I
N Level I
S Level I N Level II
N Level I
4:
N Level I
ANALGESIC MEDICINES
S Level I
S Level I
U
Level I
U Level I
N Level I
N Level I
N Level II
U Level II
S Level II
U Level II
U Level II
U Level II
N
Level III-1
N Level III-2 SR
U Level III-2
N
Level III-2
N Level III-2
U Level III-3
N Level III-3
U Level IV
S Level IV
N Level IV
opinion.
4.1.2 Neuraxial opioids

BS
BS
BS
NR
BS
Level IV
Level I Level II
seen more commonly with hydrophilic opioids such as morphine and hydromorphone and
NR NR NR
Level IV
fentanyl or sufentanil are likely to be lower risk than the hydrophilic opioids morphine and
GL
NR
NR
BS
BS
Level II
Level II
4:
Level II
ANALGESIC MEDICINES
4.1.2.1 Intrathecal opioids
NR NR
NR
Level II Afolayan
Level III-1
Level I
Level I,
Level I
Level I
Level II
Level I
Level II
Level II
Level II
Level II
Level II
Level II
Level II
87
4.1.2.2 Epidural opioids
NR
NR NR NR
Level I
NR
NR
NR
Level II
NR NR
Level IV
NR
Level II
NR
Level IV
Level IV
Level II
Level II
Level II
88
4:
Level II
ANALGESIC MEDICINES
Level II
Extended-release epidural morphine
Level II Level II

Level II Level II
PK
Level II
Level IV
Level II
Level I
PK
compared with C
in morphine C of morphine was unchanged when
PK
Level II
Key messages
Intrathecal
N Level I
U Level I
U Level I
Epidural
N Level I
U Level
II
S Level I
89
U Level II
opinion.
U
4.1.3 Peripheral opioids
NR
NR NR NR
NR
EH EH
4.1.3.1 Intra-articular
BS
Level II
Level I Level I
Level I
Level I
Level III Level II

Level II Level II
Level II
Level II
4.1.3.2 Perineural
Level I EH
EH
4:
4.1.3.3 Topical
ANALGESIC MEDICINES
Level II Level II
Level II
Level IV SR
Level III-1
Level II
Level II
Key messages
U Level I
N Level I
S Level I
4.2 Paracetamol
NR
4.2.1 Mechanism of action
NR
NR
BS . As one of the mechanisms
EH
EH
Level I
Level I
Level I
Level I
Level I
Level I
Level I
Level I
Level I
Level I
Level I
4.2.3 Adverse effects
Level IV SR
Level IV SR
NR
NR
4:
Level I
ANALGESIC MEDICINES
Level II
NR
NR
Level IV
NR
NR
Level IV
Level III-3 SR
Level III-2
Level IV SR
Level III-2 SR
Level III-2
Level III-3 SR
Level III-3 SR
Level III-2 SR
Level III-2
Key messages
U Level I
U Level I
N Level IV
N Level I
4.3 Nonselective NSAIDs and coxibs
NR
Simmons
NR NR NR NR
NR
NR NR
NR
Level I
Level II
Level I
Level I
Level I Level I
9 Level I
Level I Level I
NR
NR NR
Level I
Level I
Level I
Level I
4:
ANALGESIC MEDICINES
Level III-2
Level I
Level III-2
Level III-2
hospital admission and all-cause mortality in the opioid cohort and similar or higher rates of
Level III-2
Renal function
NR
Level I
Level II
Level IV
Level II
Level IV
Level II
Lafrance
Level III-2
Level III-2
Level I
Platelet function
Level I
Level I .
Level II
Level II
Level II
Level III-2 SR
Level I
Level I Level I
Level I
Level I
Level I
Level I Level III-2 SR

4:
Peptic ulceration
ANALGESIC MEDICINES
Level I
Level III-2 SR
Level IV
Level II
Level II Level II
Level III-2
Level III-2
Level III-2
Chan
Level II
Blackler
NR
Level III-2 SR
Allergic reactions and NSAID-exacerbated respiratory disease
GL
management.
Level I
Bone healing
7 spinal fusion studies

Level III-2 SR
Level III-2 SR
Level III-2
97
NR
Anastomotic leakage
Level I
Level III-2
Level III-2
Level III-2
Cardiovascular
Level III-2
Level III-2
NR
EH Level III-2 EH
Central nervous system
NR
98
4:
4.3.2 Cyclooxygenase-2 selective inhibitors
ANALGESIC MEDICINES
Level I
Level I
Level I
Level I
Level II
Level I
Level II
Level II
Level II
Level II
Renal function
Level IV
Level IV
Level II
Level II
Level I
below.
99
Level I
Level I
Lafrance
Level III-2
Level III-2
Platelet function
Level II EH
Level I
Level II
Cardiovascular effects
NR
NR
Level I
Level III-2
Level I
Level III-2
Level I
Level I
Trelle
Level I
GL
Level I
Level I
4:
Level I
ANALGESIC MEDICINES
Level III-2
Level III-3
BS BS
Level III-2
Gastrointestinal
Level II
Level II Level II
Level II
Level I
Level I
Level III-2
Level II
Allergic reactions and NSAID-exacerbated respiratory disease
Level IV
Level I
Bone healing
bone healing are mainly restricted to animal
NR BS
Level III-2; Level III-2

NR NR
NR
Anastomotic leakage
Level III-2
Key messages
S Level I
N Level I N Level I
U Level I
N Level I
U Level I
S Level I
N Level I
N Level I
W Level I
U Level I
N Level I
Adverse effects of systemic NSAIDs
S Level I
W Level I U Level I
S Level I
U Level I
noncardiac surgery.
S Level I
S Level I
U Level II
N Level I
U
Level I
N Level III-2 N Level I
4:
U Level II
ANALGESIC MEDICINES
N Level III-2
S Level IV
opinion.
U
Level I
4.3.3.2
Level I
4.3.3.3
Level I
Level II
Level II
between groups.
4.3.3.4 Intravenous regional analgesia
Level II
Level II
Level II
parenteral dose.
4.3.3.5 Nerve block
Level II
4.3.3.6 Topical
Level I
was limited data on direct comparison.

Level II
Level II
Level I
Level I
Level I
Level I
4:
Level I
ANALGESIC MEDICINES
Level I
Level II
Key messages
S Level I
N Level I
U Level I
N Level I
4.4 Local anaesthetics and other membrane stabilisers

4.4.1 Systemic local anaesthetics and other membrane stabilisers
4.4.1.1 Acute pain
Level I Level I
Level I
Level I
Bell
Level II Level II
Level II
Level II
Level II
4.4.1.2 Chronic pain
Level I, Challapalli
Level I
Level I
Key messages
S Level I
N Level I
U Level I
opinion.
to use membrane stabilisers including systemic lignocaine in the management of acute

U
4.4.2 Regional local anaesthetics
4.4.2.1 Short-duration local anaesthetics
NR
The use of lignocaine in ongoing acute pain management is usually restricted to the short-
NR
Level II
4.4.2.2 Long-duration local anaesthetics
NR NR
Level II Level II
Level II
NR
4:
Lyons
ANALGESIC MEDICINES
Level II
Level II
Level II
4.4.2.3 Epidural local anaesthetics
Level II Level II
Level II Level II
Level II

Level II
Level II
Level II
Level II
Level II
Level II
Local anaesthetic/opioid combinations
Level I Level I

Level II
Level I
Level II
Level II
Level II
Level III-3
4.4.2.4 Peripheral local anaesthetics
Level II Level II
Level II
Level II
Level II
Level II
Level II
Level II
two
Level II
Level II
Level II
Level II
Level I
Level I
4:
Level I
ANALGESIC MEDICINES
Slow-release preparations for local anaesthetics
NR
Level I
Level III-2 SR
n
4.4.3 Local anaesthetic toxicity

4.4.3.1 Direct toxicity
Level IV Level IV
Level I
included in the pooled analysis.

4.4.3.2 Systemic toxicity
Level IV
Level I
Level IV
Level II EH,
Level II EH
NR
BS
NR .
Controlled human studies are only possible when looking at surrogate endpoints such as
Level II EH Level II EH Level II EH
Level II EH
NR
CR CR CR
CR CR CR CR CR CR
EH PK Level IV
Lipid emulsion therapy
Level IV Level IV
BS BS
CR
CR CR CR
CR
4:
NR
ANALGESIC MEDICINES
BS
BS Level IV
Level IV
GL GL
GL
Key messages
U Level I
U Level I
S Level I
U Level II
U Level II
U
Level II
N Level IV
N Level IV
S Level IV
U Level IV
opinion.
4.5 Inhalational agents

4.5.1 Nitrous oxide
N
analgesics.
Level I
shows that N Level IV SR
Level
I
N
Level II Level II
Level II
Level II,
Level II
Level II Level III-2 Level III-2

Level III-2 Level II Level II

Level IV
EH
A post-hoc
Level II
NR
4.5.1.1 Toxicity
NR
NR
Level IV
Level IV
N
Level IV
4:
ANALGESIC MEDICINES
Level IV Level IV Level IV CR CR
CR CR CR CR CR CR
CR CR CR CR
CR
mothers CR Level IV
NR NR
Level IV NR NR
NR Level IV
CR CR CR CR CR
NR
NR
B Toh
NR
CR CR
CR
Level IV
NR
Level II
Level II Level III-3
Level III-3
or without N
N Level II
analgesia may be limited.
Level IV
and B Level II infusions
Level II
following N
4.5.1.2 Suggestions for the use of nitrous oxide as an analgesic
•
•
serum B
•
• monitor for clinical signs and symptoms of neuropathy on a regular basis.

4.5.2
has been registered in Australia

and New Zealand for use as an analgesic in
It is as a self--administered
which dispenses
Level IV SR,
Level II
Babl
Level IV
Level IV
Level IV
Level IV Level IV
As an analgesic for
Level IV
Level IV
Level IV
Level II
4:
Level II
ANALGESIC MEDICINES
4.5.2.1 Toxicity
Level IV
NR
NR
in
Level IV
CR
Key messages
S
N S
Level I
N Level IV SR
N Level I
U
Level II
S Level II
opinion.
U
4.6 NMDA-receptor antagonists
NR
NR
NR
chronic pain states as well as opioid-induced tolerance and hyperalgesia.
NR
4.6.1 Systemic NMDA-receptor antagonists
4.6.1.1 Ketamine
NR NR NR
Sleigh NR
NR
NR NR
Perioperative use
Level I
are found following thoracic surgery but not orthopaedic and abdominal surgery due in part
Level I
Level I
they are therefore not referenced here.
Level II
4:
Level I
ANALGESIC MEDICINES
Level II
Level II
Level II
Level II
Level II
Level I
Level I
Level I
Level II
Level II
Level I
Level I
NR
Level I
Other acute pain indications
Level I
Level I
Level IV NR NR
Level IV SR
Level II
Adverse effects with short-term systemic administration of ketamine
Level I
Level IV
Level I
Level IV SR
Chronic neuropathic pain

IV ketamine is superior to placebo and comparable to IV lignocaine and IV alfentanil in the
Level I
Level I
Level IV SR
NR NR
Cancer pain
Level IV SR
Level II
Level I
Adverse effects with long-term systemic administration of ketamine
NR
NR
NR
NR
NR
Routes of systemic administration and bioavailability
PK
PK
PK
4:
PK
ANALGESIC MEDICINES
4.6.1.2 Dextromethorphan
Level I
Level II
Level II
Level II
Level II
Level II
Level III-1
4.6.1.3 Magnesium
Level II
Level I
Level I
Level I
Level I
Level II
Level II
Level II
Level II
Level II
Level II
Level II
Level II EH
Level II
Level I
Level II
Level II
Level II
4.6.1.4 Amantadine and memantine
Level II
Level II
Level II
Level II
Level II
Key messages
N Level I
S Level I
N Level I
4:
ANALGESIC MEDICINES
S Level I).
N Level I
N Level I
R Level I
S Level II
8. U Level II
N Level II
opinion.
N
4.6.2 Regional NMDA-receptor antagonists
4.6.2.1 Ketamine
Neuraxial
NR NR
BS
Level II
Level II
Level II
Level I Level I
Level I NR
Level II
Peripheral sites
Level II
Level II
Level II
Level II
Level II
Viscomi
Level II
Topical administration
Topical ketamine-amitriptyline did not reduce chemotherapy-induced peripheral neuropathic
Level II
4.6.2.2 Magnesium
NR
Level I
Level I
Level II Level II
Level II
NR
Level II Level II
Level II
Key messages
U Level I
N Level I
4.7 Antidepressant medicines

4.7.1 Acute pain
4.7.1.1 Tricyclic antidepressants
Level II
Level II
Level II EH
Level II
4:
4.7.1.2 Serotonin–norepinephrine-reuptake inhibitors
ANALGESIC MEDICINES
Level II
Level II
4.7.2 Chronic pain
Level I
Level I
Level I
Level III-2
Level I
Level
I
Level I
Level I
4.7.2.3 Selective serotonin-reuptake inhibitors
Level I
Level I
Level I
Level I
Level I
Level I
Level I
Level I
Level I
Level I
Level I
Level I
GL
Pooled diagnoses
TCAs
•
• Imipramine
HIV-related neuropathies
Fibromyalgia
Pooled diagnoses
Amitriptyline
Pooled diagnoses
Amitriptyline
4:
Key messages
ANALGESIC MEDICINES
S Level I
S Level I
N Level I
S Level I
N Level II
opinion.
in the
S
4.8 Anticonvulsant medicines

4.8.1 Acute pain
4.8.1.1 Alpha-2-delta ligands (gabapentin/pregabalin)
Level I
Level I and
pregabalin Level I
Level I
Level I
Level I Yu
Level I
Level I
Level I
Level II
Level II
4.8.1.2 Sodium valproate
Level II
Level II
Level II
4.8.2 Chronic pain
Level I
4.8.2.1 Alpha-2-delta ligands (gabapentin/pregabalin)
Gabapentin
( Level I
Level I
Level II,
Pregabalin
Level I
Level I
Level I
4.8.2.2 Carbamazepine
Level I
4.8.2.3 Oxcarbazepine
Level I
4:
4.8.2.4 Phenytoin
ANALGESIC MEDICINES
Level II
4.8.2.5 Valproate
Level I
Level I
4.8.2.6 Lamotrigine
Level I
4.8.2.7 Lacosamide
Level I
Key messages
S Level I
N Level I
S S U
U U Level I
opinion.
4.9 Alpha-2 agonists

4.9.1 Systemic alpha-2 agonists
and
Level I
chronic pain or hyperalgesia remain unclear due to lack of data.
Key message
S Level I
4.9.2 Regional alpha-2 agonists
NR
4.9.2.1 Neuraxial
Clonidine
NR
pain.
Level II EH
Level I
Level I
Agarwal
Level II Level II
Level I
Level II
with or without fentanyl.
Level II,
h
Level II
Level II
Level I,
Level II
Level II
4:
Level III-2
ANALGESIC MEDICINES
Dexmedetomidine
NR
Level I
Level I
Level I
Level II
Level II
Level II
Level II
Adrenaline (epinephrine)
Level I
Level I
PK
Level II
Level II Level II
Level II
Level II Level II,
Level II
4.9.2.2 Peripheral nerve block
Clonidine
Level I
Level II Level II
Level II
Level I
Dexmedetomidine
Level I
Level II
Level II
4.9.2.3 Intravenous regional anaesthesia
Level II Level II
Level II Level II
Level II
Level II
4:
ANALGESIC MEDICINES
Clonidine
Brill
Level I
Level II
Level II
Dexmedetomidine
Level II
Level II
Level II
Key messages
S Level I) N Level I
N Level I
N Level I
S Level I
Q Level I
S Level II
W Level II
U Level II
4.10 Salmon calcitonin and bisphosphonates

4.10.1 Calcitonin
NR
a greater potency than mammalian forms of the hormone and is therefore reproduced as a
NR
Level I
Level IV
placebo Level II CR
Level II
Level I
Level II
Level IV
Level I
Level II
Level I
NR
Level III-2
4.10.2 Bisphosphonates
Level II
Level II
Level I
Level I
Level I
Level I
Zhu
Level I
NR
4:
Key messages
ANALGESIC MEDICINES
Q Level I
S Level I
U Level II
S Level II
4.11 Cannabis, cannabinoids and cannabimimetics

4.11.1 Pharmacology
9 9
NR
BS
BS
Level IV NR
NR NR
presently designated subtypes CB and CB . CB receptors are predominantly distributed
NR
The endogenous cannabinoid system can be considered complementary to the endogenous
BS
NR NR
NR
NR Level II
EH Level II Level IV
NR
EH
Level II EH Level II PK Level II EH
Level I
Level I
Level I
Level II
Level
9
Level III-3
9
Level II
Level II
EH
Level I
Level II
Level IV SR
Level II
Level I
Level IV SR
4:
n
ANALGESIC MEDICINES
Level II
Level I
Level II
Level IV
Level III-2 SR
NR NR Level III-3 Level IV
NR
Level IV
Level IV
Key messages
U Level I
U Level I
N Level I
4.12 Corticosteroids
4.12.1 Systemic corticosteroids
NR
NR
NR NR NR NR
Level I
Level II
Level II
Level I
Level II Level II
Level II
Level II
Level I
Level I
Level II
NR NR
methylprednisolone and ketorolac reduced secondary hyperalgesia and increased pain
Level II EH
Level II
Dexamethasone
Level I
Level I
Level I
4:
Level I
ANALGESIC MEDICINES
Level I
Level II
Level II
Level II
Level II where the
Level II
Methylprednisolone and prednisolone
Level II
Level II
Level II
Level II
NR NR NR NR
NR
Hyperglycaemia
Level II
Level II
Level III-2
Level II
Level II
Infection risk
Level II
Level II
Level III-2 Level III-2 Level III-2

Level III-2
Level III-2
Bleeding risk
Level I
Malignancy recurrence
Level II
Level III-2
Key messages
S Level I
N Level I
N
Level II
opinion.
N
4.12.2 Regional corticosteroids

4.12.2.1 Neuraxial
Level II
Level II
Level II
Level II
Level II
4:
Level II
Level II
ANALGESIC MEDICINES
Level II
Level II
Level I,
Level I, Level I,
4.12.2.2 Perineural sites
Level I
Level II
Level II
Level II
BS
BS
NR
BS
4.12.2.3 Peripheral sites
Level II
Level II
Level II
Level II
Level II Level II
Level II
Level II
Level IV
Level I
Level I
Level II
Level II
Key messages
U Level I
U Level I
N Level II
U Level II
N Level II
U Level II
S Level IV
opinion.
N
N
4:
4.13 Other regional analgesic medicines
4.13.1 Midazolam
ANALGESIC MEDICINES
A
NR
BS
BS
Level I
reported.
Level I
Level II
Level II
Level II
Level II
Level II
Level I
Level II
Level II
4.13.2 Neostigmine
NR
Level I
Level I, Level II
Level II
Level II
Level II
Level I
Level I
NR
Level II
Level I
Level I
Level I,
4.13.3 Botulinum toxin A
Level I
Level I
Level I
4:
Key messages
ANALGESIC MEDICINES
U Level I
S Level I
U Level I
U Level I
4.14 Complementary and alternative medicine
Belgrade
NR
Level II
Level II
Arnica montana
Level I Level II
Level II
Level II
followup.
Level II
Level II
A meta-analysis on homeopathic Hypericum perforatum
Level I Hypericum perforatum
Level II
Salix alba
Level I
Harpagophytum procumbens
Capsicum frutescens
than placebo.
Level I
Level II
Level II
Level II
Level II
Level III-2 Trigonella foenum-
graecum
Level II Shirazi
thymus vulgaris Level II
Level II Anethum graveolens
Level II
Level II Level II
Level II
Apium graveolens
Pimpinella anisum
Level II
be considered before their use.
Key messages
Salix alba Harpagophytum procumbens
N Level I
Arnica montana N Level I
Hypericum perforatum N Level I
N Level II
N Level II
opinion.
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Anaesth
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15
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88
58
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722
Knee Surg
Sports Traumatol Arthrosc 20
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30
response study. Anesth Analg 104
neonate. Anaesthesia 65
18
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blockade. Anesthesiology 99
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39
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Open
3
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J Pain Palliat Care Pharmacother 19
Pediatrics
118
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Anesth Analg 104
labour. Complement Ther Med 19

Lancet 361
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Care 39
Clinical Pain Management: Acute
Pain
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Arch Neurol 57

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Int J
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Cochrane Database
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Interact Cardiovasc Thorac Surg 14

53
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22
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Anaesthesia 56
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anesthesia. Anesthesiology 93
Cochrane
Database Syst Rev 2

Br Med Bull 47
CMAJ 182
69
anesthesia. Anesth Analg 98
Br J Anaesth 102
4:
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Br J Anaesth 109
Pain 111
analgesia. AANA J 69
46
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Anesth Analg 114
Anesth Analg 117
J Clin Anesth 11
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Health Syst Pharm 68
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dysmenorrhea. Int J Gynaecol Obstet 115
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Dan Med Bull 42
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Database Syst Rev 12

Rev 3
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107
105
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14
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Drugs Aging
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30
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Anesth Analg 110
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Anaesthesia 64
compendium of case reports. Pain Manag 4

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pain in adults. Cochrane Database Syst Rev 5
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15
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BMC Complement Altern Med 12
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Pain
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J Pain Res 5
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migraine? Cephalalgia 11
21

Curr Med Res Opin
27
tonsillectomy. Clin Otolaryngol 38

Anesth Analg
72
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Pain Med 13
randomised placebo control trial. Homeopathy 96
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10
24
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19
Cochrane Database
Syst Rev 1
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Clin J Pain 23
Pain 124
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J Neurol Neurosurg Psychiatry 60
Anesth Analg 106
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Pain 104
high thoracic epidural analgesia. Anaesth Intensive Care 33
Pain Physician 16
Pharmacotherapy 32
Anaesthesia 62
Br J
Pharmacol 163
blind trial. Br J Gen Pract 63

Indian J Anaesth 58
A case report. Iran J Neurol 12
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treatment of lumbar spinal stenosis. Yonsei Med J 50

4:
ANALGESIC MEDICINES
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Drugs 71
Br J Pharmacol 160
Br J Pharmacol 160
Anesthesiology 109
J Res Med Sci 11
J Anesth 27
of aspirin in human platelets. 721
Anaesthesiol 29
Can
J Anaesth 38
339
JAMA 255
Ann Otol Rhinol Laryngol 123
11
27
J Arthroplasty 26
Schizophr Res 130

Reg Anesth
Pain Med 26
Anesth Analg 108
upper abdominal surgery. Br J Anaesth 76
Anesthesiology 83
surgery. Anesth Analg 88
Anesth Analg 81
Anesth Analg 85
Anesth Analg
69
240
Anaesthesist 55
deaths. Possible risk factors for fatal outcome. Forensic Sci Int 220
Br J Anaesth 105
Anesth Analg
95
J Neurol 260
Neuroradiology 41
randomised case control study. Singapore Med J 52
Basic Clin Pharmacol Toxicol 111
Pain Med 13
J Clin Anesth 17
Anaesthesia 53
Paediatr
Anaesth 24
Br J Anaesth 105
older adults with hip fracture. J Am Geriatr Soc 59
17
parenterally. 27
Pharmacol Rev 56
Arch Surg 137
Muscle Nerve 37
controlled trial. BMC Clin Pharmacol 10: 9.
Br J Anaesth
limb surgeries. Indian J Anaesth 54
Obes Surg 24
15
Trends
Anaesth Crit Care 4
Pain Physician 11
metabolites. 27
13
Int J Clin
Pract 68
Anesthesiology 100
Cochrane
Database Syst Rev 7
Arch
Intern Med 170
the cross trial safety analysis. 117

J
4:
report. 48
ANALGESIC MEDICINES
Anesth Analg 113
Br J Anaesth 105
BMJ Support Palliat Care 4
Open
Complement Med J 4
Nat Clin Pract Rheumatol 4
back pain. Spine 28

Pain
105
8
Proc Natl Acad Sci U S A 87
therapy. Pharmacological Reviews 63
Anesth Analg 86

Proc Am Thorac Soc 1
Anesth Analg 97
JAMA 275
around a skin burn injury and increase pressure pain thresholds. Acta Anaesthesiol Scand 51
Int J Obstet Anesth 22
a matched case-control study. J Gastrointest Surg 18
intake. Pain Med 12
Anesth Analg 99
J Opioid Manag 5
case-control study. 99
Anesth Analg 106
Dis Colon Rectum 55
Basic Clin Pharmacol Toxicol 107

Curr Opin
Anaesthesiol 22
thoracotomy. Anesthesiology 105
study. Indian J Anaesth 56
in cannabis. Drug Metab Dispos 36

Clin J Pain 23
Med 41
Clin Ther 34
Gastroenterology 134
J Clin
Anesth 9
Anaesthesiol 15
J Opioid Manag 9
injury. Arch Phys Med Rehabil 91
Anesth Analg 106

Can J
Anaesth 53
Can J Anaesth 54
Anesth Analg 104

337
phenomenon? Curr Pain Headache Rep 15

Best Pract Res Clin Anaesthesiol
28
N Z Med J 100
J Anesth 27
Anesth Analg 101
meta-analysis. BMJ 342

Bonica’s Management of Pain
Anesth Analg 101

blinded study. Biomed Res Int 2014

Anesth Analg
98
labor pain. Anesth Analg 98

Br J
Anaesth 96
Anesth Analg 100

Anesthesiology 115
CNS Drugs 28
4:
ANALGESIC MEDICINES
23
Ann Hematol 93
HSS J 4
Cochrane
Database Syst Rev 1
opioid drugs. F1000Prime Rep 6: 79.
Anesthesiology 105
relief? Anesth Analg 102
Anesth Analg 101
Anesth Analg 113
work? 32
J Palliat Med 13
skin ulcers. 14
Can J Anaesth 58
Anesth Analg 101
J Surg Orthop Adv 23
neuropathy. Diabetes Care 37
arthroplasty. Am J Ther 13
Anesthesiology 102
Clin J
Pain 30
Acute Pain 7
J
Trauma Acute Care Surg 77
Br J Anaesth 110
Anesth Analg 95
Anesth Analg 95
BMJ 333
Mol Genet Metab

Anesthesiology 50
36
CMAJ 178
ambulatory laparoscopic surgery. Acta Anaesthesiol Scand 52
J Anesth 28
J Clin Anesth 18
Anesth Analg 106
humans. Br J Anaesth 85
burn pain. Cochrane Database Syst Rev 6

Acta Neurol
Scand 112
J Med Imaging Radiat Oncol 59

Arch
Facial Plast Surg 9
Pain Med
13
Arch Intern Med 167
for labour analgesia: a two-centre randomised blinded controlled trial. BJOG 121
Toxicol Rev 25
mitochondria. Anesthesiology 92
Anesthesiology 88
. 21:
abdominis plane blocks for cesarean analgesia. Reg Anesth Pain Med 39
24
treatment of pain. Pain Med 9

Pain
Med 9
Br J Anaesth 87
Br J Anaesth 64
anesthesia: a placebo-controlled study. Anesthesiology 102

.
Cochrane
Dig Dis Sci 44
Anesthesiology 91
4:
ANALGESIC MEDICINES
Pain Pract 14
J Pain 14
in neuropathic pain. J Pain 9
Pain 135
Cochrane
Database Syst Rev 2
Pain 80
Life Sci 69
PLoS One 9
J Clin
Anesth 27
Acta Neurol Taiwan 16
Pain 11
Anesth Analg 98
Science 192
Biopharm Drug Dispos 24
fractures. Am J Surg 207
Anesthesiology 104
Can J
Anaesth 60
J Med Toxicol 8
Indian J Anaesth 58
placebo-controlled trial studies. Korean J Fam Med 33
dysmenorrhea. 15
Anesthesiol Clin 30
Anesth Analg 119
38
4
J Gastroenterol 49
Anesth Analg 107

illness. J Crit Care 29
disease-related pain: a case series. Clin J Pain 26
JAMA 296
Br J Anaesth
106
ambulatory surgery. J Pain Symptom Manage 28
4
clinical trials. Pain Med 14

Cochrane Database
Syst Rev 2
dysmenorrhoea. BJOG 112
Pediatr Radiol 37
J Clin Anesth 14
damage. Clin J Pain 24
humans. J Psychopharmacol 22

5. ADMINISTRATION OF ANALGESIC MEDICINES
5:
ADMINISTRATION OF ANALGESIC MEDICINES
Bandolier
NR
analgesia.
5.1 Oral route
Level I Level I
Level I
Level I
Lower
Analgesic
comparison
787
5: ADMINISTRATION OF ANALGESIC MEDICINES
8.8
9.9
7.8
Lower
comparison
78
Analgesic
Lower
Analgesic
comparison
7.7
Source: Compiled with data from Moore 2003 (Level I

and Moore 2011 (Level I
5.1.1 Opioids and tramadol
NR
Level IV
Level IV
5.1.1.1 Immediate-release formulations
EH
•
Level I
Level I
Level II
Level I
•
Level I
Level II
5:
•
Level I

Level I
•
Level I
Level I
Level II
Level II
NR
Level II
5.1.1.2 Controlled-release formulations
NR
Level II Level II
Level II
Level II
Level IV
Level II
Level II
NR
Level II
5.1.2 Paracetamol
Level I
NR
PK
PK
5.1.3 Nonselective NSAIDs and coxibs
Level I
Key messages
U Level I
U Level I
U Level I
U Level II
opinion.
U
U
U
5:
5.2 Intravenous route

5.2.1.1 Intermittent intravenous bolus doses
established.
Level III-3
Bounes
Level II
Level II
Level II
NR
Level IV
Level II
Level II
Level II
Tramadol IV
Level II
Level II
5.2.1.2 Continuous infusions
Level I
Level IV
Level II
5.2.2 Paracetamol
Level I
Level I
Level I
should be limited to clinical circumstances where use of the enteral route is not appropriate.
Level I
Level II
Level II
Level II
Level I
Level I
Level II
Level II
Level I
5:
Key messages

U Level I
an increased risk of respiratory depression compared with other methods of parenteral

U Level IV
opinion.
5.3 Intramuscular and subcutaneous routes
Level IV
Level I
Level I
Level III-3
Level I
Level IV
Level IV
Level II Level IV
Level II
Level II
Level II,
relief was the same but the incidence of pruritus lower compared with PCA hydromorphone
Level II
NR
Level II
Level I
Level I
Key message
U Level II
5.4 Transdermal route
5.4.1 Opioids
The stratum corneum of the epidermis forms a major barrier to the entry of medicines.
PK NR
Level IV
NR
Level II
Level II
Peng
NR
Level II
5:
Level II
unsuitable for acute pain management.

NR
Level II
5.4.2 Other medicines
Level I
Level II
Key messages
should not be used in the management of acute pain because of safety concerns and
Q Level IV
opinion.
5.5 Transmucosal routes
metabolism. The medicines most commonly administered by transmucosal routes in acute

pain management are the more lipid-soluble opioids.
5.5.1 Rectal route
5.5.1.1 Opioids
NR
Level II
5.5.1.2 Paracetamol
Level I
NR
Level II
Level IV and total
Level II
Level II
Level II
Level IV
Level II
therefore preferable.
Level IV
Level IV
Level IV
Level II
Level III-1
5.5.1.3 NSAIDs
Level I
Level I
5.5.2 Intranasal route
NR
NR
NR
5.5.2.1 Opioids
NR NR
5:
NR

T
PK
fentanyl
Level I
Level I
Level I
Level IV SR
Level II
Level II
Level II Level IV
Level II Level IV Level IV
Level II Level II
Level II
Level II
Level II
NR NR
NR
5.5.2.2 NSAIDs
Level II
Level II
Level II
5.5.2.3 Ketamine
Level II
Level IV Level IV
Level IV
5.5.3 Sublingual and buccal routes

5.5.3.1 Opioids
NR NR
Level I
Level I
Level I
NR emc
Oral transmucosal fentanyl citrate
NR
Level II
Level II
Level II Level II
Level II
Level II
Level II
the management of acute pain.

Fentanyl buccal tablets
NR
NR
Level I
Level I Level I
Level II
Sublingual fentanyl citrate orally disintegrating tablets
NR
NR
Level I
Level II
Level IV
5:
NR
NR
Level I
Other transmucosal fentanyl preparations

Lotsch
NR Zeppetella
Level I
PK
Sublingual buprenorphine
NR NR
Level II
Level II
Level II
5.5.3.2 Ketamine
PK
PK
PK
5.5.4 Pulmonary
5.5.4.1 Opioids
area and permeability of the lungs.
Level IV Level II
Level II Level II
Level II
Level IV
PK
PK PK
PK
Level II
Level II
5.5.4.2 Other analgesic medicines
Key messages
S Level I
N Level I N Level I
N Level I
opinion.
5.6 Epidural analgesia
NR
Level I Level I Level I

Level I Level I
Level I
Level I
Level III-2
Level I
Level I
5:
Level I
Level I
.
5.6.1.2 Cancer surgery outcomes
Level I
Level III-3 SR
Open abdominal surgery
Level I
Level I
Level I
Level III-2
Level III-2
Level II
Level II
Level II
Level II
Level II
Level II and was superior to IV PCA morphine
Zhu
Level II
Level II Bertoglio
Level II
Laparoscopic colectomy
Level III-2
Level I
Level I
Level III-2
Level II
Level III-2
Hepatic surgery
Level IV
Level III-2
Level II
Level
III-2
Level II
Level II
Level III-2
Abdominal aortic surgery
Level I
Level III-1
Level III-2
Level III-2
Level II
5:
Gynaecological surgery
In

Level II
Level III-2
NR
Urologic surgery
Level II
Level III-2
Level II
Thoracic surgery
Level III-2
Level II
Level II
Andreae
Level I
Cardiac surgery
Level I
Level I
Bignami
Level I
Level III-3
Level II
Level II
Level III-3
Level II
Level II
Level II
NR
Rib fractures
Level I
Level II
Level III-2
Orthopaedic surgery
Level II
Level II
Choi
Level II
Level I
Chloropoulou
Level II
Vascular surgery of the lower limbs
Level II Level II
Pierce
Level IV Level IV
5.6.1.4 Level of administration
Level I
Level II
Level I
Level I
Level II
Level I
Level IV
Level III-2
Level III-3
5:
remaining in situ Zaouter
Level II
Level III-3
Level III-3
5.6.2 Medicines used for epidural analgesia
5.6.2.1 Local anaesthetics
Level II Level II
5.6.2.2 Opioids
Level I
n Level I
NR
5.6.2.3 Local anaesthetic-opioid combinations
Level I
Level II
Level II
Level II
Level II
Level IV
5.6.2.4 Adjuvant medicines
5.6.3 Patient-controlled epidural analgesia
Level IV Level IV Level IV Level IV

5.6.3.1 Comparison with continuous epidural infusions
Level I
block.
Level II
Level II
5.6.3.2 Concurrent background (continuous) infusions
Level II
Level II
Level IV Liu
Level IV
Level II
Nolan
Level II
Level II
5.6.3.3 Medicines used in postoperative patient-controlled epidural analgesia

5:
5.6.4.1 Neurological injury

Level IV
Level IV SR
million
Level IV SR
Brull
Level IV SR
Level IV
Level IV
Pumberger
Level IV
Level IV

5.6.4.2 Epidural haematoma
Level IV
Level IV
Level IV
GL
Level IV SR
Level IV
Level IV
Bracco
Level IV
Level IV SR
Level IV
GL
5.6.4.3 Epidural abscess
catheter was in situ

Level IV
Level IV
Level IV
Level IV
5:
Level IV
Level IV SR
Level I
Level II
GL
GL
BS
An in vitro
Staphylococcus
aureus and
of Pseudomonas aeruginosa
Level III-2 S aureus
faecalis and P aeruginosa
against
NR
NR
GL
5.6.4.4 Respiratory depression
The incidence of respiratory depression with epidural opioid analgesia depends on the criteria
Level IV
5.6.4.5 Hypotension
The incidence of
Level IV
Level I
Level IV
changes.
5.6.4.6 Treatment failure
NR
Level IV
Level I
Level II
Level II
5.6.4.7 Other
There has been concern among surgeons about increased risk of
Level I
Level III-2
Level III-2
5:
Key messages

U Level I
U Level I
S Level I
S Level I
N Level I
S evel I
N Level I
N Level I
Level III-2
N Level I
U
Level I
U Level I
S Level I
‐impregnated dressings of epidural catheters in comparison to placebo‐ or
‐iodine‐
U Level I
N Level III-2
U
Level II
S Level IV
U
Level IV
opinion.
5.7 Intrathecal analgesia

5.7.1 Medicines used for intrathecal analgesia
IT
NR
5.7.1.2 Opioids
IT
Level IV
Level I Level I
Staikou
Level I
Level I Level I
5:
Level I
Level II
Level II
Level II
Level II
Level II
Level II
Level I
Level II
Level II
Level II
Level II
Level II
Level II
Level I
Level II
Level II
Level II
Level I
Opioid-induced ventilatory impairment
NR
Level IV
Level II
Level IV
Level IV
Level IV EH
Level IV
Level I
Level I
Level I
more pronounced with IT morphine than with IT fentanyl.
Level I
Level IV
5:
Level IV NR
Pruritus
Level I
NR
Level I
NR
Level II
Level II
Level I
Level I
Level I
Level II
NR
Level II
Level II
Nausea and vomiting
Level I
Level I
Level II
Level II,
Level II
Urinary retention
The incidence of
Level I Level I
Level I
Other adverse effects
Level II
Level III-2
NR
Level IV
CR
5.7.1.4 Adjuvant medicines
Clonidine
Level I
Magnesium
Level I
Key messages
S Level I
S Level I
5:
N Level I)

Q Level I
N
Level I
N Level I
N Level I
opinion.
U
(N).
5.8 Other regional and local analgesic techniques
5.8.1 Continuous and single-injection peripheral nerve blocks
Ilfeld
NR NR
Level I
Level I
5.8.1.1 Upper limb
Interscalene and suprascapular nerve block
Level II
Level II
Level II
Level II
CR
Verelst
NR
Level II
Other brachial plexus blocks
Ilfeld
Level II
Level II
Level II
5.8.1.2 Lower limb
Level IV
Level III-3
Femoral nerve block
Level I
Level II
Level II
Fascia iliaca block
Level II
5:
Level II

Level II
Adductor canal block
and block of both likely contributes to analgesia for knee surgery. An adductor canal block
Level II
Level II
CR
Level II
Level II Level II
Level II
Level II
elucidated.
Sciatic nerve
Level II Level II
Level I
Lumbar plexus
Level II
Level II
5.8.1.3 Thoracic
Paravertebral block
Level IV and
NR
Level I
Level II
Level I
Level II
Level II
Level II,
Level I
Level I
Intercostal and interpleural block
Level II
Level I
Level I
Level II Level II
Level II
Level II
Level IV
Level I
Level II
analgesia following open cholecystectomy but not following laparoscopic cholecystectomy or

NR
Pectoralis nerve block
Level II
5:
Abdominal wall block

Level I
Level I
Level II
Level II
Level II Level II
Level
Level II
Level II Soltani
Level II Level II
CR CR
Level IV
Adjuvant agents to perineural blocks
Needle and catheter localising techniques
Level I
Level I
Level I
Level I
Perineural catheters
Level II Level II
Level II
Level II Level II
Level II
Level II
Level II
NR
5.8.2 Periarticular and intra-articular analgesia
Level IV Level IV
BS
Level I
Level I
NR
Total knee arthroplasty
Level I
Level II Level
II Level II
Level I
Level II Level II
per se
Level II
Level II
Level I
Level II
5:
Total hip arthroplasty
In total hip arthroplasty

Level I
Level II
Level II
Level II
Level II
including wound catheters
Level I
Level I
Level I
Liu
Level I
Level I
Level I
Level II
Level I
5.8.4 Topical application of local anaesthetics
Level I
Level I
Level I
Level I
8 Level I
Level I
Level I
Level I
NR
5.8.5 Safety
Level IV Level IV
Level IV
Level IV
GL
5.8.5.1 Anticoagulation
5.8.5.2 Nerve injury
Level IV
Level IV
Level IV
Level IV
Level IV
Level IV
surgical factors and that the incidence of neuropathy directly related to peripheral regional
Level IV Level IV
5.8.5.3 Toxicity
Level IV
Level IV
Level IV
CR
5:
Level IV Level IV

5.8.5.4 Infection
GL
NR
NR
NR
Level 2
Level II
Level IV
Key messages
U Level I
N Level I
S
Level I
N Level I
S Level I
U Level I
N Level I
S Level I
U Level I
S
N Level I
N Level I
N Level
I
Q
Level I
N Level I
N Level I
N Level I
Q Level II
weakness (N) Level II
N Level II
N Level IV
N
Level IV
opinion.
N
5:
5.9 Regional analgesia and concurrent anticoagulant medications
5.9.1 Neuraxial block and epidural haematoma

GL
Level IV
Level IV
Level IV
Level IV
GL
GL
NR
GL
GL GL
GL
GL
GL GL
•
the risk of spinal haematoma but should be regarded as a risk factor if combined
GL
•
•
• Low molecular weight heparin —
GL
GL
GL
• Oral warfarin
GL
•
• SSRIs —
GL
5:
• Herbal therapy Ginkgo biloba
Panax Angelica sinensis

GL
5.9.2 Plexus and other peripheral regional block and anticoagulants
GL
Level IV
with a femoral catheter for total knee joint replacement in situ
Level IV
Level IV GL
CR CR
Level IV
GL
Key messages
U Level IV
opinion.
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20
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J Anesth 20
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Am J Sports Med 35
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26
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Arthroscopy 27

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4
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Br J Surg 98
Anesthesiology 98
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thoracotomy pain: a randomised controlled study. 29
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54
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J Med Assoc Thai 94
hysterectomy. Pain Pract 11
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J Int Med Res 40
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38
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analgesia and hypocaloric glucose. Reg Anesth Pain Med 32
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Closed Claims Project. Int Anesthesiol Clin 49
29
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Clin
Pharmacokinet 52
BMC Clin Pharmacol 10
Anesthesiology 108
Ann Thorac Surg 79
Anaesthesia 67
Anaesth Intensive
Care 39
5:
pharmacodynamics. Anesth Analg 115

23
23
Anesth Analg 108
colorectal surgery. Br J Surg 94
subjects. Br J Clin Pharmacol 41
Can J Anaesth 53
Postgrad
Med 125
Reg Anesth
Pain Med 35
intramuscular morphine in the treatment of postsurgical pain. Can J Anaesth 40

Br J
Anaesth 108
intrathecal morphine for post-caesarean analgesia. Int J Obstet Anesth 19
pain. 28
Ann Card Anaesth 13
Anesthesiology 120
J Clin Pharmacol 37
Support Care Cancer

13
J Clin Monit Comput 22
Br J Anaesth 102
Chest 128
postcesarean analgesia. J Clin Anesth 22

MIMS Annual 2014
14
J Clin Anesth 20
Res Rep Urol 5
Anaesthesia 61
Can J Anaesth 59
Anesth
Analg 119
pethidine. Acta Anaesthesiol Scand 34
Anesthesiology 101

Anesth Analg 107
abdomen. Br J Anaesth
Pain 69
Anesth Analg 100
Br J Anaesth 110
J Pediatr
Health Care 25
Ann Card Anaesth 15
J Arthroplasty 25
Reg Anesth Pain Med
39
J Opioid Manag 7
double-blind and placebo-controlled trial. Pain Res Manag 17
J Laryngol Otol 122
Pain. Reg Anesth Pain Med 40
anesthesia and pain medicine. Reg Anesth Pain Med 33
J Opioid Manag 4
J Arthroplasty 27
Br J Anaesth 98
Anaesthesia 69
Anaesthesia 47
111
Reg Anesth
Pain Med 37
Anaesthesia 64
Anaesthesist 62
48
5:
Ann Vasc Surg 26

controlled analgesia. Can J Anaesth 47
Saudi J Anaesth 7
Anesthesiology 113
Anesthesiology 90
thoracotomy pain. Br J Anaesth 75
30
J Vasc Surg 25
chronic non-malignant pain. Drugs 71
Schmerz 27
abdominal and thoracic surgery: a meta-analysis. Arch Surg 143
Pain 153
Ann Surg 259
J Hosp Infect
Reg Anesth Pain Med

38
53
spine surgery. J Spinal Disord Tech 23

Neurosurg Rev
23
14
opioids? A meta-analysis. Anesth Analg 102
undegoing gynecologic surgery with an abdominal incision: a randomised clinical trial. Acute Pain 9
25
22
Anesth Analg 102
Br J Anaesth 88
27

Anesth Analg 103
Anesthesiology 105
BMC
Anesthesiol 6
Acta
56
subcutaneous morphine boluses. Acute Pain 9
12
Med Sci Monit 19
Anesth Analg 117
Anesth Analg 95
Br J Anaesth 106
Anesthesiology 81
Anaesthesist 41
Anesth Analg 100
Br J Anaesth 105
J Hosp Infect 86
Can J Anaesth 59
upper abdominal surgery. Br J Anaesth 76

Pain 55
Ann Vasc Surg 12
Anesth Analg 81
incidence of catheter dislodgement. 2014
pain in children. Br J Anaesth 76
Anaesthesia 52
study. Biomed Res Int 2014
Acta Clin Croat

53
J Clin Anesth 17
5:
J Burn Care Rehabil 19

Am
28
Curr Drug Deliv 5
Int J Clin Oncol 20
Pain Med 11
Curr Med Res Opin

26
clinical registry. Reg Anesth Pain Med 37

Health Qual Life Outcomes 4
Br J Anaesth 84
Pain Med 15
Clin Ther 31
Minerva
Anestesiol 80
clinic. 30
J Clin Anesth 16
J Opioid Manag 8
double-blinded trial. Anesth Analg 104
Br J Anaesth 87
Pain Med 9
management. Can J Anaesth 42

Anesth
Analg 76
Br J Clin Pharmacol
49
programme. Colorectal Dis 15

J
Clin Pharmacol 36

Anesth Analg 109

Ir J
Med Sci 180
Reg Anesth 18
bunionectomy surgery. Anesthesiology 99
pain in adults. Cochrane Database Syst Rev 1

42
catheters. J Nurs Care Qual 28
Anesth Analg 73
the elderly. Acute Pain 8
Anesthesiology 120
Cardiovasc Intervent Radiol

36
Anesthesiology 115
Br J Surg
100
Reg Anesth Pain Med
38
in cancer. Curr Med Res Opin 26
adults undergoing knee arthroscopy and meniscal repair. AANA J 80
design. Clin Ther 35
Anesthesiology 91
Anaesthesia 57
Anesthesiology 98
J Pain 11
group study. Clin Ther 27

Br J Anaesth 87
Anesth Analg 97
Lancet 372
surgery with and without a background infusion. Anaesthesia 55
analgesia. Pain Med 8

Anaesthesia 45
Anesthesiology
103
5:
J Clin Anesth 18

J Clin Anesth 18
Int J Obstet
Anesth 16
Anesth Analg 117
Neurourol Urodyn 30

Can J Anaesth 43
104
Bone Joint J 95-

B
Anesth Analg 115
Biopharm Drug Dispos 24
Anesth Analg 116
the emergency department: a pilot study. 25
Anesthesiology 108

Cochrane
epidural lidocaine. 125
Gastric Cancer 16
worth it? J Cardiovasc Thorac Res 6

6. PATIENT-CONTROLLED ANALGESIA
6:
PATIENT-CONTROLLED ANALGESIA
trauma and with cancer.
6.1.1 Analgesia, patient preference and outcomes
Level I
Level II,
Level II
Level II
Level II Level II
Level IV SR
Level I
NR NR NR
6.2 Cost of PCA
NR
Level II Level III-2 Level II
Level III-2
Palmer
Level III-3
6.3 Medicines used for parenteral PCA

6.3.1 Opioids
Level II
6.3.1.1 Morphine
Level III-2
NR NR
NR
Level III-3 PK
morphine less suitable for IV PCA use than other opioids. Limited clinical data suggest that
Level III-2
6.3.1.2 Fentanyl
fentanyl
Level II
Level II
Level II
Level III-2
Level II
6.3.1.3 Tramadol
Level I
6:
. Tramadol also has a lower risk of respiratory depression
6.3.1.4 Hydromorphone
Level IV
Level II
Level III-2
Level
II
Level
II
6.3.1.5 Oxycodone
Level II,
Level II
Level II
6.3.1.6 Pethidine

Level II
Level II Level II
Level II
Level II
6.3.1.7 Methadone
Level II,
NR
6.3.1.8 Other opioids
Level II
Level II
Level II
6.3.1.9 Opioid combinations
Level II
Level II
Level II
Level II
Level II
6.3.1.10 Adverse effects of PCA opioids
Level II
Level IV SR Level IV
SR
Level IV
Level IV
Level I
Level I
Level I
Level I Level I
Level I
6:
6.3.2 Adjuvant medicines
6.3.2.1 Antiemetics
Level I
Level II
Level II
Level II
high doses of droperidol.
Level II
Level I
Level II
Level II
Level II
Level II
6.3.2.2 Ketamine
Level I
6.3.2.3 Naloxone
Level II
6.3.2.4 Other adjuvants
Level II Level II
Level II
Level II
Level II
Level II
Level II,
Level II
Level II
Level II,
Level II,
6.4 Program parameters for IV PCA
6.4.1 Bolus dose
Level II
was associated with an increased risk of respiratory depression and a conclusion was made
Level II
dose.
Level II
Level II
NR NR
Level IV
Level IV
Level II
6:
Level IV
6.4.2 Lockout interval
Level II
6.4.3 Concurrent background (continuous) infusions
Level I
Level II
6.4.4 Dose limits
NR .
6.4.5 Loading dose
NR NR
GL
NR NR
6.5.1 Subcutaneous PCA

Level II Level II
Level II Level II
Level II
Level II
Level II Level II
6.5.2 Oral PCA
Level II
Level IV
Level II
6.5.3 Intranasal PCA

Level II
Level II
Striebel
Level II Level II
Level II
Level II
Level II
NR
6.5.4 Transdermal PCA
Level I
Level IV PK
6.6 Safety and complications related to PCA
Level IV
Level IV
Level IV
6:
Level IV
Level IV
the leading cause of PCA errors.
Level III-3 Level IV SR

n
Level III-3
Level IV
a common and standardised form and process that incorporates human factors and safety
GL
6.7 Equipment
6.7.1 Programmable PCA pumps
access code.
6.7.2 Disposable PCA devices
6.7.2.1 Parenteral PCA devices
NR
NR
6.7.2.2 Intranasal PCA devices
Level II Level II
Level IV
Level III-1
6.7.2.3 Transdermal PCA devices
NR
NR NR
6.7.3 Equipment-related complications
Level IV
CR
CR
CR CR
CR
CR CR
CR
CR
CR
GL
6:
6.8 Patient and staff factors
6.8.1 Patient factors
6.8.1.1 Education
Level IV
Level IV
Level III-2
Level II

6.8.1.2 Inappropriate use of PCA
CR Level IV CR Level IV Level IV

Level IV
CR Level IV CR
CR CR
6.8.2 Nursing and medical staff
based.
Level IV
Level IV Level IV
general-purpose infusion pumps and lead to more harm than errors in other types of
NR
Level IV Level IV
CR
Level IV
Key messages
U Level I
U
Level I
U Level I
U
Level I
Q Level I
N Level I
(N) (Level I
incidence of respiratory depression (S) (Level I)

U Level II
U Level II
U Level II
U Level II
U Level II
6:
N Level II
N Level III-3
N Level IV SR
S Level IV
opinion.
References
analgesia. Clin J Pain 10

Br J Anaesth 108
Anaesthesia 40
-a meta-analysis. Can J Anaesth 53

Drug Delivery Report
Br J Anaesth 96
Am J
Obstet Gynecol 197
19
Anesthesiology 116
24
Anesth Analg 87
Br J Anaesth 104
Br J Anaesth 93
Pain 96
Pain 107
Anesth Analg 83
J Adv Nurs 46
Int J Med Inform 74
Clin
J Pain 25
Acta
Br J Anaesth 87
13
Anaesthesia 48
administered intramuscular opioid therapy. Anesthesiology 89

Anaesthesia 53
Anaesthesia
53
J
Adv Nurs 39
about nothing. Anaesthesia 59
Pain 72
Am J Obstet Gynecol 207
Anesth Analg 97
Can J Anaesth 50
J Adv Nurs 30
J Clin Anesth 26
Br J Anaesth 95
published data. Br J Anaesth 89
18
Can J
Anaesth 55
Anesthesiology 94
Health
Devices 24
Health Devices 25
Health Devices 26
Health Devices
31
Health Devices 35
22
6:
Urology 45
Pain Pract 8
Pain Med 9
Anesth Analg 80
analgesia following gynecological surgery. Pain 62
31
Am J Health Syst
Pharm 65
Br J Surg 75
Anesth Analg 107
anaesthesia: a comparison of fentanyl with morphine. Can J Anaesth 42
Hosp Pharm 41
Br J Anaesth 89
surgery. J Clin Anesth 20
Can J Anaesth 55
Br J Anaesth 90
and pharmacodynamic aspects. Clin Pharmacokinet 42
Medsurg Nurs 8
Am
J Health Syst Pharm 62
22
Anaesthesia 50
J
Clin Anesth 13
Br J Anaesth 110
Anesth Analg 109

controlled analgesia. Br J Anaesth 102

J Clin Anesth 17
analgesia therapy. J Clin Anesth 8


23
Pain 64
38
Can J Anaesth 49
Anesthesiology 102
Br J Anaesth
106
errors. Hosp Pharm 44
Pain Pract 14
Crit
Care Med 20
J Neurosurg 111
Anesth Analg 87
J Opioid Manag 6
J Anesth 28
Anaesthesia 54
general hospital. Anaesthesia 45
Drug Saf 37
Anaesthesia
44
Anaesthesia 44
study. Anaesthesia 58
database analysis and literature assessment. Clinicoecon Outcomes Res 6
JAMA 266
Anesthesiology 76
Can J Anaesth 45
6:
errors. Anesthesiology 113
Anesth Analg 84
meta-analysis. Acute Pain 11

Anesth
Analg 99
43
controlled analgesia. Anesth Analg 82
cell disease. Br J Haematol 120
35
Int J Technol Assess Health Care 15
J Support Oncol 5
Anaesthesia 59
J Clin Anesth 23
controlled analgesia. Anesthesiology 99
Drug Saf 32
J Clin Anesth 17
J Pain
Symptom Manage 14
16
Arch Surg 137
Anesthesiology
71
Anesthesiology 70
Anaesthesia 66
Br J Anaesth 76
Br J Anaesth 71
management. Can J Anaesth 42
Anesth Analg 83
Anaesthesia 48
Anesth Analg 86
Dis Colon Rectum 55
incidents. Anaesthesia 43
Can J Anaesth 47
Anesth Analg 88
Anaesthesia 52
20
25
subcutaneous hydromorphone. Anesthesiology 69
Can J Anaesth 50
Anesth Analg 70
Anaesthesia 57
Pain
Med 9
Clin J Pain 6
Pain 64
Pain 80
J Clin Nurs 16
pain. Br J Anaesth 101

Br J Anaesth
106
7. NONPHARMACOLOGICAL TECHNIQUES
7:
NONPHARMACOLOGICAL TECHNIQUES
7.1 Psychological interventions
The role of
common features. Some of these features may also apply to pharmacological and physical
hold for their outcome. These aspects may be seen as necessary to gain both the informed
Level III-2 SR
•
•
•
7.1.1 Provision of information

is
Level IV
Level I
Level I
Level I
Level III-1 SR
Level II
Level III-3 SR
n
Level I
Level III-3
SR
Level I
Level II
Level II
Level II
7.1.2 Stress and arousal reduction
7.1.2.1 Relaxation
Level I
Level I
Level III-3 SR
7:
Level II
Level III-1 SR
8 studies
8 studies
inconsistent changes in endocrine measures reported.
Level I
7.1.2.2 Hypnosis
NR
NR
Level III-1 SR
Level I
Level I
Level I ,
Level I
7.1.3 Attentional techniques
Level II
NR
Level I
Level I
Level I
Level
I,
Level III-2 EH
Level III-2 Level III-2 NR
NR Level III-2 Level II
NR
Level IV
Level I EH
Level II EH
Level II EH
There are no data on mindfulness or acceptance methods in the management of clinical acute
joint replacement has been published

7.1.4 Cognitive-behavioural interventions
7:
needed.
7.1.4.1 Applying pain coping strategies within a cognitive-behavioural intervention
NR Level II NR
Level III-2
NR
Level I
NR
of children and adolescents with cancer pain undergoing a wide range of cancer-related
NR
NR
NR
Level II
Level III-3
Level II =
meet for three occasions in an informal way with a physical therapist to discuss coping and
Level II
Level I
Key messages
S Level I
Q Level I
S
Level I
Q Level I
Q Level I
N Level I
Q Level I
U Level I
Q
Level I
U Level I
U Level III-2
7:
7.2 Transcutaneous electrical nerve stimulation
Level I
Level I
Level II,
Level I
Level I Level I
Level I
7
Key messages
N Level I
N Level I
N Level I
Q Level I
7.3 Acupuncture and acupressure
auriculotherapy.
7.3.1 Postoperative pain
Level I
Level I
below.
7.3.1.1 General surgery
Level II
Level II
Level II
Level II
Level II
Level IV
7.3.1.2 Orthopaedic surgery
Cho
Level I
Level I
Level II Level II
Level III-1
Level II
7.3.1.3 Cardiac surgery
Level II
Level II
Level II
7.3.1.4 Gynaecological and obstetric surgery
Level II
7:
Level II
Level II
Level II In the only adult trial to employ
Level II
Level I
Level II
Level III-1
7.3.1.5 Ear, nose and throat surgery
Level II
Level II
7.3.1.6 Children and adolescents
Level II
Level IV Level IV
7.3.2 Other acute pain states
7.3.2.1 Emergency department and acute trauma setting
Level I
Level II
Level III-3
Level IV
hip fracture
Level II Level II
Level II
7.3.2.1 Acute back pain
Level I
Level II
Level II
Back Pain
GL
7.3.2.2 Labour pain
Level I
NR Level
I
Level II
Level II
7.3.2.3 Dysmenorrhoea
Level I
Level I,
Level I
Level I
Level II
7.3.2.4 Dental pain
Level I
Level IV
7.3.2.5 Acute neuropathic pain
Level II
7.3.2.6 Headache
7:
Level I
Level
I
GL
Level II
7.3.2.7 Children and adolescents
Level II
Level II
Key messages
S Level I
N Level I
S Level I
S Level I
N Level I
N Level I
S) Level I N Level I
N Level I
N Level II
7.4 Physical therapies

7.4.1 Manual and massage therapies
Level II
evel II
Level II Albert
Level II
Level II
Level II Level II
Level IV)
Level II
Level II
Level III-2
Level I
Level II
Level III-2
Level I
Level I
Level
I
GL
7.4.2 Warming and cooling intervention
Level I
Level II Level III-1 Level II Level III-2 Yu

Level II

Level II
Level II
Level II
Level III-1
Level II
Level I
Level II
Level I
Level I

7:
Level IV Level II
Level III-1
7.4.3 Other therapies
7.4.3.1 Magnet therapy/magnetic stimulation
Level I
Level II
Level II
Level II Level
Level II
7.4.3.2 Low-level laser therapy
Level I
Level II
Level II
7.4.3.3 Healing touch
Level II
Level I
7.4.3.4 Preoperative exercise (“prehabilitation”)
Level
IV SR
Key message
opinion.
References
Pain Manag Nurs 15
J Res Med Sci 18

Int J Dermatol
51
Heart Lung
38
pain. Am J Obstet Gynecol 167
trials. J Holist Nurs 29

Pain
Manag Nurs 13
J Altern Complement Med 16
Thorac Cardiovasc Surg 63
Arthroscopy 14
13
Complement Ther Med 21
Health Psychol 12
Complement Ther Clin Pract 16
Midwifery 27
Photomed Laser Surg 24
Anesthesiology 105
43
cooling of the wound. Anaesthesia 51
J Thorac Cardiovasc Surg 144

Anesth Analg 104
coughing post-cardiac surgery. Can J Cardiovasc Nurs 20
2012
BJOG 117
BJOG
117
Pain Pract 15
28
electroacupuncture following coronary surgery. Neurosciences 15 (1)
Pain Manag Nurs 15
Acupunct Med 29

7:
of using perineal warm packs in the second stage of labour. Midwifery 25
BMC Pediatr 5
J Adv Nurs 54
in a group of Turkish pregnant women. Appl Nurs Res 23

Curr Sports Med Rep 10
repair: a randomised placebo-controlled trial. Acupunct Med 28
Trials 15
labour. Cochrane Database Syst Rev 2

Clin J
Oncol Nurs 16
of children with cancer. Acta Oncol 38
childbirth. Cochrane Database Syst Rev 5
Am J Sports Med 24
Acupunct Med 27

Br
Dent J 184
J Clin Nurs 21

Psychooncology 22
Am Surg 72
Pain Manag Nurs 13
J Acupunct Meridian Stud 7
J Adv Nurs 37
puncture. Respir Care 60

Ann Behav Med
23
Pain Med 14
Biomed J 37
for acute burn pain during medical procedures. Ann Behav Med 41
during physical therapy: a controlled study. Clin J Pain 16
Anesth Analg 105
47
Pain 47
J Adv Nurs 50
Cochrane
Database Syst Rev 6
Ann Behav Med
15
Clin Psychol: Sci Pract 10:
Acute Pain 11
J Physiother 60
Annu Rev Psychol 36
Ambul Pediatr 8
Anesth Analg 95
43
psychophysiological arousal in women undergoing colposcopy. J Behav Med 36
Am J Sports Med 24
Cochrane
Database Syst Rev 5
Based Complement Alternat Med 2014

Soc Sci
Med 51

J Nurs Scholarsh
38
and pain following spinal fusion surgery. Nurs Res 52
Acupunct Med 28
25
J Gastrointest Surg
6
Complement Alternat Med 2011

Clin J Pain 29
stage. J Obstet Gynecol Neonatal Nurs 42

Hip
Int 22
Am J Knee Surg 8
Paediatric Anaesthesia 19
dysmenorrhea. Pain Med 15

Psychosom Med 57
Physiother Theory Pract 29

7:
Psychooncology 10
Altern Ther Health Med 14
Cochrane
J Anesth 24
2013
pilot study. J Altern Complement Med 17
Pain 131
Cochrane Database
Syst Rev 1
Rev Bras Fisioter 15
Pain 83
Arch Surg 142

J Clin Nurs
23
Anesth Pain Med 4
Int J Pediatr Otorhinolaryngol

77
burned adolescents. J Burn Care Res 31

J Anaesthesiol Clin
Pharmacol 25
J Am Coll Surg 197
CMAJ 177
J Pediatr Psychol
24
primary dysmenorrhoea. Cochrane Database Syst Rev 1

J Natl
Cancer Inst 93
BMC Musculoskelet Disord

13
Arch Phys Med Rehabil 92

Cochrane
Database Syst Rev 9
J Med Assoc Thai 93
J Arthroplasty 19
Physiotherapy 100
Ann Plast Surg 53

Rev Bras Cir Cardiovasc 27
J Adv Nurs 27
17
Pain 154
J Clin Nurs 18
randomised trial. J Physiother 59
Scand J Prim Health Care 31

Cochrane
Database Syst Rev 7
in labour. Cochrane Database Syst Rev 2
pain. Hawaii J Med Public Health 72
chronic pain and disability following whiplash injury. Phys Ther 86
Clin J Pain 17
pain: a meta-analysis. J Consult Clin Psychol 57
Br J Anaesth 101
controlled trials. Clin Ther 31
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60
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Psychological Approaches to Pain
Management
children and adolescents. Cochrane Database Syst Rev 10
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a randomised controlled trial. 12
randomised controlled clinical trial. Pain 153 (9)
longitudinal randomised controlled trial. BMC Complement Altern Med 14

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8. SPECIFIC CLINICAL SITUATIONS
8:
SPECIFIC CLINICAL SITUATIONS
8.1 Postoperative pain
discussed later in this chapter.

8.1.1 Multimodal postoperative pain management
NR
NR
NR NR NR NR
Level II
Level II
Level II
Level II
Level II
Level III-3
Level III-3
Key messages
N Level II
opinion.
NR NR NR
Level I
NR
NR
NR NR
. The methodology
NR; NR
NR
Level I
• Level I
• Level I
•
• Level I
• Level I
• Level I
• Level I
•
• Level I
•
•
8:
Key messages

N Level I
opinion.
N
8.1.3 Acute rehabilitation after surgery, “fast-track” surgery and enhanced
recovery after surgery
The concept of
NR NR NR
NR
Level I
NR
only one.
Level I
Level I
Level IV
Level IV
Level IV NR
NR NR NR
Level III-2
Key messages
N Level I
opinion.
N
8.1.4 Risks of acute postoperative neuropathic pain
NR
NR
Level IV
Level IV
Level IV
Level IV
Level IV
GL NR
Level IV Level IV
8:
Key messages

S Level IV
opinion.
Treatment of acute neuropathic pain should follow guidelines for chronic neuropathic
U
8.1.5 Acute postamputation pain syndromes
Level IV Level IV Level IV NR
• Stump pain
Level IV NR
Level IV
•
Level IV
• Phantom pain
Level IV
NR NR
Level IV
Level IV
Level III-3
Level III-3
Level IV Level IV
Level IV
Level IV
Level III-3
Level IV
8.1.5.1 Prevention of phantom limb pain
Level III-2 SR
Level III-2 SR
Level III-3
Level II
Level II
Level II
Level III-SR Level I

8.1.5.2 Therapy for phantom limb pain
NR
Level III-1 SR
morphine
also has
Level II
Level I
Level III-1
Level II
Level II
Level III-1
Level III-2 SR Level IV
Level II
Level IV
Level IV
Level I
Level II
8:
Level IV

Level IV
Level IV
Level IV
Level IV
Key messages
S Level I
Q Level I
S Level I
S Level I
S
Level II
U
Level III-2
opinion.
U
8.1.6 Other postoperative pain syndromes
to the more detailed study of some of them. The progression from acute to chronic pain
8.1.6.1 Post-thoracotomy pain syndrome
Post-thoracotomy pain syndrome is one of the most common chronic pain states. The
Level IV SR
Level IV
Post-thoracotomy pain syndrome is thought to be caused primarily by trauma to intercostal
NR
Level III-3
by itself is not a predictor for this pain syndrome and other factors need to be present.
Level IV
Level IV
Level I
Level I
NR
8.1.6.2 Postmastectomy pain syndrome
Level IV Level IV
Level IV
Level IV
Level III-
3
Level IV
Level IV
Level III-2
Level IV
Level IV Level IV Level III-2
Level IV
Level IV
Level III-2
Level I
Level II
Level II
Level II
Level II
Level III-2
Level II
8.1.6.3 Postherniotomy pain syndrome
Level IV
8:
Level IV

Level IV
Level III-3
Level II
Level III-2
Level III-2
Level III-3
Level IV
Level III-3
GL
8.1.6.4 Posthysterectomy pain syndrome
NR
NR
Level III-3
Level IV
Level IV
Level II
Level II
Spinal anaesthesia in comparison with general anaesthesia reduced the risk of chronic
Level IV
Level II
Key messages
S Level I
S Level I
S (Level I
N Level IV
8.1.7 Day-stay or short-stay surgery
procedure.
Level IV Segerdahl
Level IV
Level IV
Level IV
Level IV
Level III-2
NR
Level II
Level II
Level IV
Level IV
Level IV
8.1.7.1 Adverse effects of pain
Level IV
Level IV Level IV The most common reason for unplanned hospital

Level III-2
Level IV
8:
8.1.7.2 Analgesic drugs and techniques

NR
•
•
•
Paracetamol, nonselective NSAIDs and coxibs
Level II
Level II
Level II
Level II
Opioids
Level II
Level II
Systemic adjuvant drugs
Level II
Level II
Level II
Local anaesthesia techniques
NR
Level II
Level II
Level II
Level I
Level I
when applied before the commencement of pneumoperitoneum and use of aerosolised
Level I
Single-injection peripheral nerve block
NR
Level IV
Level IV
Ilioinguinal and iliohypogastric block
Level II
Level II
Level II
Level II
Level II
Level II
Transversus abdominis plane blocks
Level II
Level II
Level II
8:
Level II
Level II
Paravertebral block
Level II
Level II
Level IV
Level II =
Level II
Level II
Upper and lower limb blocks
Level II Level II
Level III-3
Level IV
Level II
Level IV; Level IV Level IV
Level II
Level IV
Pelvic plexus block
Level II
Paracervical block
Level I
Adjuvants to single-injection peripheral nerve block

Dexamethasone
Level II
Level II
Level II
Dexmedetomidine
Level II
Level II
Level II
Buprenorphine
Level II
Level II Level II
Level II
Ketamine
Level I
in vitro
NR
Continuous peripheral nerve block
Upper and lower limb blocks
Level IV
Level II
Level II Level II Ilfeld
Level II Level II
Level II
Level II
Level II
Level II
Level III-3
8:
Level IV

Level II
Level II
Level IV
Level IV
Paravertebral blocks
Level II
Level II
Safety and management of continuous peripheral nerve blocks in an ambulatory setting
Level IV Level IV; Level IV

NR
Level IV
Level IV
Level IV
Level IV
NR; NR
Discharge analgesia
Alam
Level IV
8.1.7.3 Nonpharmacological techniques

ambulatory surgery. Pressure on acupoints decreased pain following knee arthroscopy
Level II
Level II
Level II
Key messages
N Level I
N Level I
N Level I
N Level II
S Level II
S Level II
S Level II
N Level II
N Level II
N Level II
U Level IV
U Level III-3
U Level IV
8.1.8 Cranial neurosurgery
Level IV Level IV;

Level IV
Level IV
Level IV
Level IV
Level IV

8:

Level IV
Level IV
NR
Level IV
Level IV
Level IV
Level IV
Nemergut
NR
8.1.8.1 Treatment of acute postoperative pain after cranial neurosurgery
Level I
Paracetamol
A trial comparing
Level II
Level IV
Nonselective NSAIDs
Level II
Level II
Level IV
Coxibs
Level II,
Level II
Opioids
Level II
Level II Sudheer
Level II Sudheer
Level II
Level II Level II
Level II
Level II
Level II Level II
Local anaesthetic scalp block
Level I
Level II
Level IV
Adjuvant drugs
Level II
Level II
Level II
Physical therapies
Level II
Key messages
S
Level I
U Level II
U Level IV
U Level III-2
U Level IV
opinion.
N
8:
8.1.9 Spinal surgery

8.1.9.1 Paracetamol
Level II
8.1.9.2 NSAIDs
Level I
Level III-3 SR
8.1.9.3 Opioids
Level II
8.1.9.4
Level II
Level II
Level II
8.1.9.5 Adjuvants
Alpha-2-delta ligands (gabapentin and pregabalin)
Level I
Level II Level II
Level II Level II
Level II
Level II
Dexamethasone
Level II
Lignocaine
Level II Level II
Ketamine
Level II
Magnesium
Level II
Epidural analgesia
Key messages
N (Level I)
N Level I
N Level II
N Level II
N Level II
N Level III-3
opinion.
8.2 Acute pain following spinal cord injury
Level IV
chronic pain syndrome.
Bryce
GL
GL
8:
Neuropathic
pain compression
eg spinal cord compression or ischaemia
pain
Visceral
GL; Bryce
GL
8.2.1 Treatment of acute neuropathic pain after spinal cord injury
following SCI.
Level IV).
Level IV).
Siddall
GL
8.2.2 Treatment of chronic neuropathic pain after spinal cord injury
8.2.2.1 Opioids and tramadol
Level II
Level II n=
Level II
BS
administering high doses of opioids in the acute period post injury.

8.2.2.2 Ketamine
Level I
8.2.2.3 Membrane stabilisers
Level I
Level II
Level II
Level II
Level II
Level I
8.2.2.4 Antidepressants
Level II
Level II
Level I
Level II
8.2.2.5 Anticonvulsants
Level I
Level II Level II
Level II
Level II
8.2.2.6 Cannabinoids
The
Level II
8.2.2.7 Intravenous anaesthetics
An IV bolus of low-dose propofol reduced the intensity of central neuropathic pain and
Level II
8.2.2.8 Nonpharmacological treatment
Level III-2
Level III-1
Level II
8.2.3 Treatment of nociceptive and visceral pain after spinal cord injury
8:
Key messages

S Level I
S Level I
U Level II
opinion.
8.3 Acute burns injury pain
NR
Level I
NR
and psychological reasons but also to facilitate procedures such as dressing changes and
NR; Level IV Level IV
Level IV Level IV
Sheridan
Level III-3
Level III-3
8.3.1 Management of background nociceptive pain
NR
NR NR
GL
GL BS
burn injury. Temporary burns dressings such as cellophane type kitchen wrap and clean sterile
GL GL
Level II Level IV
Level III-2
PK NR
8.3.2 Management of acute neuropathic pain and hyperalgesia

Level IV
Level II
Parenteral methylprednisolone or ketorolac reduced secondary hyperalgesia surrounding an
Level II
Level I Level II
Level I EH
8.3.3 Management of procedural pain
NR
nonpharmacological approaches.
8.3.3.1 Opioids
Level IV
Level II
Level IV Level IV
Level II
Level II
Level II Level II
8.3.3.2 Adjuvants
N Level IV
Level II
Level I
Level I EH
8:
Level IV

Level III-1
Level III-1
Level II
Level II
The heterogeneous nature of the studies and the lack of pain outcome data in a meta-analysis
Level I
Level II =
Bidwell
Level III-2 Coimbra
Level IV
Level II
Level IV
Level IV
Level II Level IV
Level II
Level I
Level II
Level II
8.3.4 Regional analgesia for donor site pain management
Shteynberg
Level IV
Level II
8.3.5 Nonpharmacological pain management
Level III-2
NR
Level II
Level IV SR
Level II
Level III-3
Level III-2
Level II
Level II
Level IV
Level II
Key messages
U Level I
S Level II
U
Level II
S Level II
N Level II
N Level II
U
Level III-3
U Level IV
opinion.
8.4 Acute back pain

8:
GL
SR SR
studies
lower limb pain and other neurological symptoms.
increased risk of progression from acute to chronic pain. Such factors should be assessed early
GL
GL
include those produced by:

•
GL GL GL
• GL
• GL
•
GL
GL
Key messages
U Level I
U Level I
U Level I
U Level I
U Level III-2
U Level III-2
8.5 Acute musculoskeletal pain
based Management of Acute Musculoskeletal Pain

Australian Acute
GL
GL
GL
GL
Key messages
U Level I
U
Level I
U Level I
U
Level I
U Level I
U
Level I
opinion.
A management plan for acute musculoskeletal pain should comprise the elements
U
8:
8.6 Acute medical pain

Level IV
Level IV
Level IV
8.6.1 Acute abdominal pain
8.6.1.1 Analgesia and the diagnosis of acute abdominal pain
Level I Level II
Level II
Level I
8.6.1.2 Renal and ureteral colic/stones
Level I
Level I
Level I
Level II Level II
Level I
Level II
Level II
Level II
Level II
Level II
Pethidine has commonly been used in the treatment of renal colic in the belief that it causes
Level II .
Level II Level II
Level II Level I
Level II
Level II
Level II =
Level I
Level II
Level III-1
Level I
Level II
8.6.1.3 Biliary colic and acute pancreatitis
NR
Level IV
Level I
Level I
Level II
Level I
Level II
Level I
Level I
8.6.1.4 Irritable bowel syndrome and colic
Level I
Level I
Level I
8.6.1.5 Primary dysmenorrhoea
The management of primary dysmenorrhoea embraces both biological and psychosocial
clinical trials restricted to single agents.
Level I
Level I
8:
Level I

Vitamin B Level I
Level I Level II
Level II
Level II Level II Level III-1
Foeniculum vulgare Level III-2
dysmenorrhoea.
Level I
7 Level I
Level I
8.6.1.6 Recurrent abdominal pain (abdominal migraine)
Level I Level I
Level I
Key messages
U Level I
U Level I
U Level I
N Level I
U Level I
S Level I
S Level I
S
Level I
N Level I
N Level II
S Level I
N Level I
N Level II
U
Level II
8.6.2 Herpes zoster-associated pain
NR
NR
NR
8.6.2.1 Prevention of herpes zoster
Level I
Level II
Level III-3
8.6.2.2 Treatment of herpes zoster-associated pain
Antiviral agents
Level I Level II
Level II
NR
Opioids, tramadol and paracetamol
NR; NR; NR
recommended.
8:
Level II
Corticosteroids
Level II
Level II
Anticonvulsants
Berry
Level II Level II
Level II
Level II
Topical lignocaine
Level II
Aspirin
Level II Level II
Neuraxial or sympathetic block
Level IV SR
Level II
Level II
Level IV SR
8.6.2.3 Prevention of postherpetic neuralgia
Level I
Level I
Level I
Level II
Level IV SR studies
Level II
Level II
Key messages
U Level I
S Level I
S Level I
U Level II
U Level II
opinion.
U
8.6.3 Acute cardiac pain
Acute coronary syndrome refers to a range of acute myocardial ischaemic states including
Level I
Level I
GL
GL
Level I
Level IV
8:
Level IV

cardiac failure.
Level II
Level II
Level III-2
Level II
Level II Nielsen
Level II
Level II
Level II
Level II
N
Level II
NR
Key messages
U Level II
U Level IV
opinion.
N
8.6.4 Acute pain associated with haematological disorders
8.6.4.1 Sickle cell disease
NR
Level IV
abdominal organs can mimic an acute surgical abdomen. Acute chest syndrome secondary to
NR
GL
Treatment of pain
GL
GL
Level III-2
Opioids
GL
GL
Level II
Level II
with low constant infusion or lower demand dose and higher constant infusion did not lead
Level II
Level III-3
Although IV opioid PCA is widely accepted in the management of acute pain in sickle cell
Level II
Level III-3
Level III-3
Level II
Care must be taken when using opioids in the treatment of pain in sickle cell disease. In a
Level IV
NSAIDs
Level II Level II
Corticosteroids
Parenteral
Level I
8:
Level II

Ketamine
low-dose Level IV
Level IV NR
Inhaled nitric oxide
Level II
Inhaled nitrous oxide

Inhaled N
GL
Oxygen
Level II Level II
Level IV
Level III-3
Rehydration
Level I
Epidural analgesia
Level IV
Prevention of painful sickle cell crises
Level I
Level I
Level II Al
Level I
8.6.4.2 Haemophilia
Level IV
Level IV
Level IV
Level II
NR
Level IV
8.6.4.3 The porphyrias
The acute porphyrias are a group of inherited disorders of haem biosynthesis. The most
NR
Level II
NR
NR; NR
CR
NR NR
BS
CR
CR
Anderson
NR
Key messages
S
Level I
U Level I
U Level I
N Level I
8:
S Level II
U Level II
N Level III-3).
opinion.
U
8.6.5 Acute headache
GL NR
GL GL GL Beithon
GL GL
8.6.5.1 Tension-type headache
GL
GL GL
Level II
NR
GL
Treatment
Level I
Level I
Level I
Level II
8.6.5.2 Migraine
GL
Level IV
Treatment
acute recurrence.
NR
either:
•
•
•
NR
Strategies for the use of migraine medications

There are three major strategies for the use of analgesics in the treatment of acute migraine
Level II
•
GL
GL
GL
Placebo
Level I
Level I
8:
Level II

Simple analgesics
GL
Level I
Level I
Level I
Level I
Level I
Level II
Triptans
All
Level I
GL NR
Level I
Level I
Level I
Thorlund
Level I
Level I
or placebo.
NR
Level III-2
Level III-2 SR
NR
Level IV
Ergot derivatives
NR
Level I
Level I
Level I
Level III-2 SR
Opioids and tramadol

Tepper
NR; NR
Level III-2
NR; NR
Level IV
NR
Level I
Level I
n Nicolodi
Level III-1
Antiemetics and major tranquillisers
Level I
8:
Level I

Level II
Level II
Level II
Level II
Level II
Level II Level II
Other drug treatments
Level I
Level II Level II
Level II
Level I
Level IV SR
Level VI
Level II
Level II
Level II
Level IV Level IV
Level IV Level IV
GL
Tanacetum parthenium
Cady
Level II
Level VI
Hyperbaric oxygen therapy
Level I
8.6.5.3 Menstruation-related migraine
NR
Level I
but with higher rate of recurrence and less sustained suppression of nausea in the menstrual
Level I
8.6.5.4 Migraine in pregnancy and breastfeeding
NR
Level IV NR
Level III-2
NR
NR
small risk of uterine atony and haemorrhage with use during the second and third trimesters
Level III-2
Level IV
NR
Level III-2
metoclopramide are considered safe for the treatment of acute migraine in mothers
NR; NR; Level IV SR
8.6.5.5 Cluster headache and other trigeminal autonomic cephalalgias
GL
Oxygen
Level I
Level II
Level IV
Level I
8:
Level II

Triptans
Level I
Other treatments
NR GL
lacking.
Level IV
NR
Level IV SR
NR; NR
Level IV Level II
8.6.5.6 Paroxysmal hemicrania and SUNCT
GL
GL
Level IV Level IV
8.6.5.7 Postdural puncture headache
NR; NR)
chronic headache. Children who undergo lumbar puncture may present a special group
NR
Spinal needle size, type and lumbar puncture technique
Level I
Level II
Level II
Level II
Level I
Level II
Level II
Level II
Level II
NR
Level II
Epidural blood patch

The use of an
NR NR
NR
Level I
Level II
Level IV
Level III-1
Level IV
Level II
NR
Level I
Level II
Level IV
Bed rest and hydration
Level I
Other treatments
Level I
8:
• Level II
Level II
•
Alam
Level II Level II
Level II
• Level II Level II
Level II Level IV
Level II
Level II
• Level III-1
Level III-2).
•
Level II
NR; NR
8.6.5.8 Other headaches
Silberstein
GL
Giant cell arteritis

The treatment of
Level II
Headache attributed to substance withdrawal (severe analgesic “rebound” headache)
NR
Key messages
Tension-type headache
W Level I
S Level I
N Level I
Q Level I
Migraine
S Level I
S Level I
N Level I
N Level I
N Level I
Level II
S
Level I N Level I
S Level I
N Level I
N Level I
N Level III-2
U Level I
N Level I
U Level II
U Level II
N Level III-2 SR
N Level III-2
Cluster headache
S Level I
Postdural puncture headache
S Level I
S Level I
8:
Level I
S Level I
Level II
opinion.
U
8.6.6 Acute pain associated with neurological disorders
NR
8.6.6.1 Multiple sclerosis
NR
Level IV SR
NR
•
•
•
• treatment-induced pains.
Level IV SR
Level I
Level I
Level I
Level I
Level I
8.6.6.2
NR
NR; NR
8.6.6.3 Central poststroke pain
NR
NR
Level II
Level II
Level II
Level II
Level II
Level IV
GL
8.6.6.4 Trigeminal neuralgia
trigeminal neuralgia can present as acute neuropathic pain.
Level I
Level I
Level I
8:
Level I

Level IV
Level IV
Level I
Level IV
Level IV
GL
NR
Key messages
N Level I
N Level I
N Level I
opinion.
Treatment of acute pain associated with neurological disorders is based largely on
8.6.7 Orofacial pain
NR NR
psychological factors.
NR; NR
NR
8.6.7.1 Acute dental pain
Level I
Level I
Level I
NR
and has not been dealt with.

8.6.7.2 Acute postoperative dental pain
Paracetamol and NSAIDs
Level I
Level I
Level I
Level I
Level II
Level II n=
Level II =
Level I
Level II
Level II
Level II
Level I
Tramadol
Level I
Level II
A
Level I
Level II
Level II
Steroids
Level I
Level II
Level II
8:
Level II
Vegas-Bustamante
Level II
Pregabalin
Level II
Nonpharmacological treatment
Level II
Level III-1 SR
Level I
8.6.7.3 Acute post-tonsillectomy pain
Paracetamol, NSAIDs and opioids
Level I
Level II Schmidt
Level II Level II
Level II
Level I
Level I
Level I
Level I Chan
Level I
Level I
NR
Gabapentin and pregabalin
Level II
Yeganeh
Level II
Level II
Steroids
Level I
Antibiotics
Level I
Local anaesthesia
Level I
Level II
Level II
Level II
Level II
Level II
Topical administration
Level I
8.6.7.4 Acute pain associated with temporomandibular disorders
NR; NR
Level I
Level II
8:
8.6.7.5 Acute pain associated with pharyngitis

Systemic analgesics
Level I
Corticosteroids
Level I
Level I
Level II
Antibiotics
Level I
Topical analgesics
Level I
Level II
Level II
Level II
Level II
Level I
Nonpharmacological treatment
Level II
8.6.7.6 Acute pain associated with sinusitis and otitis media
Level I
Antibiotics
Level I
Steroids
Level I
Topical treatment
Level I
Level II
Cyclamen europaeum
Level II
Level I ,
Level II
GL
GL GL
8.6.7.7 Acute pain associated with oral ulceration, including mucositis
Level II
Level II
Level I
NR
Level I
Clarkson
Level I
Level II
Level I
Level I
GL NR; Level III-2
Level II
Level IV Level IV
Level IV; Level II
Level II CR
Level II Level II
8:
GL GL

Key messages
Acute dental pain
N Level I
N Level I
S Level I
N Level I
N Level II
N Level I
N Level I
N Level I
N Level I
U Level I
U Level II
Tonsillectomy
N Level I
N Level II
U Level I
S Level I
R Level I
U Level I
N Level I
N Level II
U Level II
Pharyngitis
S Level I N Level I
U
Level I
N Level I) N Level II
U Level II
Sinusitis
N Level I
N Level I
Oral mucositis
U Level I
U Level I U Level I
N Level II N Level II
U Level II
opinion.
8.6.8 Acute pain in patients with HIV infection

NR; Level IV Vogl
Level IV
NR; Level IV NR
NR; Level IV
Level IV Level IV
Level IV
Level IV
Level IV
Simmonds
NR; Level IV Level IV Breitbart

NR; Level IV Level IV
Level IV
Level IV
Level III-2
8:
8.6.8.1 Treatment of pain in people infected with HIV

below.
Level IV Level IV
Level IV
Level III-3 Level IV Level IV
NR
Level IV
Level IV
Level I
Level I
Level IV
NR
8.6.8.2 Special considerations in treating pain in patients with HIV infection
Drug interactions
.
Level II
Level III-2
Level III-2 .
maintenance doses.
NR
CR
Patients with a history of substance abuse
Level IV Level IV Breitbart

Level IV Level IV)
Level III-2
Level III-2
Level IV
Level IV
Key messages
(S) Level I
(S) Level I .
R
Level I
U Level III-2
S Level IV
opinion.
U
8:
8.7 Acute cancer pain
8.7.1 Assessment of acute cancer pain

GL
NR
GL
NR
NR
Level IV Level IV Level IV NR

Level IV Level IV
8.7.2 Principles of management of acute cancer pain
GL
GL GL GL GL
Level IV
NR
Level II
Level IV
Level I NR
Level III-2 SR Level III-3 SR
n
Level IV SR
NR
GL
underlying cause of pain may be urgent.
8.7.3 Medicines for acute cancer pain
8.7.3.1 Opioids
Level II
NR Level II
Level III-2 SR
GL GL
GL
Level III-2 SR
Level III-2
Level I
Level I
Level I
Level I
Level III-3
Level III-3
Level III-2 SR
Level III-2 SR
8:
Level III-3 SR
Level III-3 SR
8.7.3.2 Paracetamol and NSAIDs
Level III-2 SR
Level III-2 SR
8.7.3.3 Ketamine
Bell
Level IV SR
Level II
Level IV
NR NR Level IV
NR
Level II
Level IV
Level II Level II
Soto
Level III-2
Level II
8.7.3.4 Glucocorticoids
NR Level I
Level II
Level III-2 SR
NR
Level III-2
8.7.4 Breakthrough pain
Level IV Level IV SR
Level I
Level I Level I
Level I Level I
Level IV
Level I
Level IV
8.7.5 Acute neuropathic cancer pain

8.7.5.1 Incidence and diagnosis of neuropathic cancer pain
Level IV SR
8:
in the somatosensory system. Peripheral or central neuropathic pain may result from

NR
GL
8.7.5.2 Treatment of neuropathic cancer pain
NR
Level I
Level III-2 SR
Level III-2 SR
Level III-2 SR
Level IV
SR
Level III-2 SR
8.7.5.3 Painful chemotherapy-induced peripheral neuropathy

NR
GL
Level II
GL
8.7.6 Procedural pain in cancer patients
Level I
8.7.7 Acute pain due to bone cancer
myeloma. Bone pain may also be precipitated during some cancer treatments eg granulocyte-
BS BS
BS BS
8:
8.7.7.1 Diagnosis of bone cancer pain

SR SR SR
SR SR
SR
8.7.7.2 Spinal cord compression
Level III-3
SR
SR
SR
NR GL NR
NR
NR
8.7.7.3 Treatment strategies for bone cancer pain
NR
Level II
Level III-2 SR
CR
NR;
NR NR
8.7.7.4 Surgery
Level IV SR
Level IV SR
Level IV SR
Level IV
Level IV SR
Level III-3 SR
8.7.7.5 Radiation therapy
Level I
treatment for uncomplicated bone metastases indicated similar response rates following
Level I
Level II
Level IV SR
Level I
8.7.7.6 Percutaneous vertebroplasty
Level IV SR
8:
Level IV SR
CR
Level IV Level IV Level IV Level

IV Level IV
Level III-2
8.7.7.7 Bone-modifying agents
Bisphosphonates
Level I
n
NR
Bamias
Level IV
Level III-2 SR
Level I
Level I
Level I
Level I
Denosumab
NR NR NR
Level I
Level I
NR
Level III-2 SR
Level I
Calcitonin
Although
Level I
8.7.7.8 Treatment of acute malignant extradural spinal cord compression
GL
8.7.8 Other acute cancer pain syndromes

8.7.8.1 Malignant bowel obstruction
NR
Level IV
Level III-1
Level I
Level IV
Level IV
8:
Level IV SR

Level IV SR
Level IV
8.7.8.2 Mucositis
8.7.9 Interventional therapies for acute cancer pain
8.7.9.1 Peripheral nerve blocks
NR
Level IV SR
8.7.9.2 Neuraxial techniques
GL GL
Level IV SR
SR NR NR
Level IV
Ballantyne
Level IV SR
8.7.9.3 Spinal cord stimulation
Level III-3 SR
8.7.9.4 Destructive procedures
NR
Arcidiacono
Level I
Level IV SR
Level I
NR
NR
Level IV SR
Level IV
Level IV
Key messages
S Level I
S Level I
N Level I
N
Level I
S Level II
U Level III
N Level IV SR
opinion.
U
Prompt assessment and fast coordinated management of spinal metastases with
s
S
U
N
N
8:
8.8 Acute pain management in intensive care

NR
8.8.1 Pain assessment in the intensive care unit
the presence of an endotracheal tube or decreased conscious state due to illness or
Level IV
Level IV Level IV
NR
NR

NR
Level III-2
Level III-2
Level III-3
NR
Level III-1 Payen

Level III-2
Level III-3
8.8.2 Management of pain, agitation and delirium
NR
Level III-3 GL
Level II
Level III-2
Level III-1
Level II
an associated higher risk of delirium.
Barr
GL
•
•
•
•
•
•
•
-
-
-
- interdisciplinary team approach.
Level IV
8.8.3 Nonpharmacological measures
Level IV Level IV Level III-3

NR
Level II
8.8.4 Pharmacological treatment
GL GL GL
8.8.4.1 Paracetamol, nonselective NSAIDs and coxibs
NR
Level II
Level III-2
8:
8.8.4.2 Opioids

periods. The replacement of a fentanyl infusion with enteral methadone in mechanically
Level II
Level II
Level IV
Level IV
Level IV
Level I
Level II
Level IV
8.8.4.3 Alpha-2 agonists
Level I
Level II
Level II
8.8.4.4 Local anaesthesia techniques
Level I
Level I Level I
8.8.5 Guillain-Barre syndrome
NR
Level I
Level I
Level I
Level I
8.8.6 Procedure-related pain
Level IV
Level III-2
Level IV Level II
Level II
surgery was superior to placebo with the higher dose causing more respiratory depression
Level II
Level II
Key messages
R Level I
W Level I
N Level I
N)
Level II
U Level II
U Level III-1
N
Level III-1
8:
N Level III-2

opinion.
8.9 Acute pain management in emergency departments
NR
Level IV NR Cinar
Level III-3
Level IV This indicates that other

Level III-2
Level III-3
Level III-2
Level III-3
Level III-1
8.9.1 Systemic analgesics
8.9.1.1 Paracetamol and NSAIDs
Both
Level I
Level I
Level II
8.9.1.2 Opioids
Level IV
Level I
and faster analgesia.
Level IV
Level II
Level II
Level II
Level II
Level II Level IV
Level II
Level II Level II
Level III-2
Level II
Level II
Level I
Level II
8.9.1.3 Tramadol
Vergnion
Level II
Level II
Level II
Level II
Level II
Level II
NR
8.9.1.4 Inhalational analgesics
N
Level II Level II
Level II Level II
8:
Level II
8.9.1.5 Ketamine
Level II
Level II
Level II
Level I
Level IV Level IV
8.9.2.1 Abdominal pain
abdominal pain in
Level IV
Level IV
Level I
Level II Level II
Level I
8.9.2.2 Renal colic
Level II
8.9.2.3 Biliary colic and acute pancreatitis
8.9.2.4 Acute cardiac chest pain

8.9.2.5 Acute pain and sickle cell disease
8.9.2.6 Migraine
Level IV
Level I
Level I
Level I
Level I
Level I
n
GL GL
GL
other acute headache syndromes.
8.9.2.7 Fractured neck of femur
or oral analgesia administered to control pain from a
Level I
Level II
Level IV
Level IV
8.9.2.8 Shoulder dislocation
Level I
8.9.2.9 Wounds
whether analgesia following the procedure is desirable.
Level II
8:
Level I

Level II
Level I
Level I
Level II
Level II
8.9.3 Nonpharmacological management of pain
of
Level IV
Key messages
N Level I
Abdominal pain
U Level I
Migraine (see also Section 8.6.5)
S
Level I
Fractured neck of femur
N Level I
U
Level II
Local anaesthesia
N Level I
U Level I
U Level II
for wound care in the emergency department.
opinion.
8.10 Prehospital analgesia
Level IV
Level IV
Level IV
Level IV
Level IV
Level IV
Level IV
Level IV
Level IV
Level IV
Level IV
Level III-2
Level I,
8:
Level IV
Level IV
Level III-2
the following themes arose as reasons why analgesia was withheld: reluctance to administer
Level IV
8.10.1 Assessment of pain in the prehospital environment
Level II Level II Level IV

Level II Level II, Level II
Level IV Level II
Level IV
Level IV
Level III-3
8.10.2 Systemic analgesics
NR

Bruns
Level IV
Level IV Level IV
Level II
Level II
Level II
Level II Level II
Level II
Level III-2
PK
Level III-3 SR
n
Level II
analgesia in the IN fentanyl group.
Level IV
8.10.2.2 Inhalational agents
Level IV Level IV
N
Level IV
Level IV
Level IV
NR
8:
Level IV

NR
Level II,
NR
GL
Level IV
Level III-3
Level
III-2
Level IV
NR
Level IV
8.10.2.3 Ketamine
Level IV
Tran
Level II
Level II
8.10.2.4 NSAIDs and paracetamol
NR; NR
8.10.3 Anxiolytics
NR
NR
Level IV
8.10.4 Regional analgesia
Level IV
Level IV
8.10.5 Nonpharmacological management of pain
importance of
Level II
Level II
Level II
Level II
8.10.6.1 Acute cardiac pain
GL Cannon
GL Level IV
Level I
GL GL
8.10.6.2 Abdominal pain
process in acute abdominal pain.

8.10.6.3 Patients with head injury
NR
NR
8:
Key messages
N Level II
S Level II
S Level II
S Level II
N Level III-3
U Level IV
N Level IV
opinion.
8.11 Discharge medication for acute pain management
NR
GL NR
NR
8.11.1.1 Opioid-induced ventilatory impairment
NR

Level IV
Level IV
Level IV
NR Level IV
Level III-2
8.11.1.2 Patient falls
Those using opioids chronically for noncancer pain may be at greater risk of falling and
Level III-2
Level III-2
Level III-2
8.11.1.3 Impaired driving
Level IV
Level IV
Level IV
n
Level III-2
Level III-2
Level III-2 Brady
Level IV
chronic opioid use.
Level IV
Level III-2
Level III-2
Level VI
8.11.1.4 Risk of inducing long-term opioid use
Steyaert
NR
8:
Level III-3 Level III-2 Level III-2 Level III-2

Level IV
Level III-2
Level III-2 Singh
Level III-2
Level III-2
Level IV
Level III-2
Level III-2
Level IV
8.11.1.5 Risk of diversion and abuse
NR Level IV
Level IV Level IV
Level IV
Level IV
Level IV
Level IV
Level IV
Level IV
NR; Level IV
NR
Level IV Level IV
Level IV
Level IV
NR
NR; NR; NR
NR
8.11.2 Selection of opioid for discharge medication
NR GL
Level IV Level IV
Level IV
Level IV
Level IV
Level IV Level IV
Level IV
NR
NR; Level IV
NR
NR
NR
NR;
NR
NR
8:
NR; NR;

GL
Key messages
N Level III-2
N Level III-2
N
Level III-2
N Level III-2
N Level III-3
opinion.
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J Neurosurg
Anesthesiol 17
J Adv Nurs 69

J R Army Med
Corps 156
Burns 39
CA Cancer J Clin 63
Burns 38
PLoS One 8

Mayo Clin Proc 84
Pain Medicine 9
without histories of substance abuse. Clin J Pain 22
Ann Pharmacother 44
burn pain. Pain 72
dressing. J Burn Care Res 34
J Clin Oncol
32
Anesthesiology 111
Crit Care Med 29

8:
Anesthesiology 106

Cancer Treat Rev 39
Cephalalgia 33
Cardiovasc Intervent Radiol 37
BMC Public Health 8

Anesthesiology
93
in burn injuries. Ann Pharmacother 35
30
Anesth Analg 115
13
Rhinology 50
Cephalalgia 26
PLoS One 5
Pain Pract 14
Ann Intern Med 114
normeperidine. Pharmacotherapy 20
Br J Anaesth 92
51
metastases reported in randomised trials using bone-modifying agents. 25
Ann Surg 259
surgery. Clin Ophthalmol 7

Pain 41
Pain 79
21
15
Anesth
Analg 99
BMJ 348
Can J Neurol Sci 39
Neurology 70
Cochrane
Database Syst Rev 3
primary dysmenorrhoea. Cochrane Database Syst Rev 1

Am J Hosp Palliat Care 32
Crit Care Med 25

from Thunder Project II. Crit Care Med 32
Heart Lung 31
Curr Opin Support Palliat Care
6
J Fam Pract 51
Palliat Med 25
Pain Res Treat 2012
J Cardiothorac Surg 9
J Neurosurg 112
43
it worthwhile? J Burn Care Res 30

Pain Physician 16
pain? JAMA 296

Rev 7
cordotomy. J Neurosurg 114
17
Anesthesiology 96
J Pain Res 4:
cell disease. Br J Haematol 120
migraine? Cephalalgia 11
J Pain 8
Neurologist 12
25
chronic neuropathic pain in persons with spinal cord injury. Arch Phys Med Rehabil 88
pilot study. Am J Phys Med Rehabil 89
17
trial. J Pain Symptom Manage 19

Ann
Oncol 22
44
8:
Cephalalgia 35

22
Pediatr Hematol Oncol 9
J Trauma 65
Cephalalgia
28
J Hand Surg Am 37
Ann Pharmacother 31
25
14
associated with falls and fractures in elderly adults. J Am Geriatr Soc 61
case report. J Oncol Pharm Pract 21

Semin Thorac
Cardiovasc Surg 25
Radiother
Oncol 75
Cochrane
Database Syst Rev 7

Plast Reconstr
Surg 134
Int J Rehabil Res 34
controlled trial. 22
Aust Crit Care
25
Reg Anesth Pain Med
28
Anaesthesia 59
of irritable bowel syndrome. Cochrane Database Syst Rev 8
acetaminophen in pediatric tonsillectomy: analgesia and bleeding. Anesth Analg 80
Ann Oncol 23
caudal block in pediatrics. Acta Anaesthesiol Scand 53
Clin J Pain 29
post-dural puncture headache. Anesthesiology 95
treatment of acute renal colic. 48
30
Anesthesiol Clin 32
management. 19
Cardiol
Rev 11
Clin J Pain 29
on pain and blood loss. Acta Anaesthesiol Scand 45
during physical therapy for pediatric burns. Burns 37
for anorectal surgery. Int J Colorectal Dis 26
Br J Anaesth 107
Cephalalgia 33
Pain Manag 2
headache. Headache 47
department: a randomised double-blind controlled trial. 29
15
trial. J Clin Virol 29

Acta
Neurol Scand 123
Crit Care Med 23
acute migraine. Headache 42
and ascites. Ann Surg Oncol 20
J Microbiol
Immunol Infect 37
the emergency department. 28
J Trauma Acute Care Surg

76
Pain 8
19
Int J Neurosci 112
J Clin Nurs 18
Burns 39
Pain Res Manag 17
laparoscopic cholecystectomy. Int J Surg 12
placebo-controlled trial. Neurology 67

8:
Spinal Cord 44

Pain 81
SIGN 106.
Neurology 55
acute ischaemic-type chest pain. 8
Burns 22
Clin J Pain 21
longitudinal study. Pain 54
14
arthroplasty. 53
Braz J Anesthesiol 63
Pain Med 4
Hernia 14
JAMA 309
J Urol 179
CNS Drugs 27
BMC
Neurol 12
BMC Urol 12
propofol: case series. 5
Br J Anaesth 111
combined with morphine and ketorolac for acute renal colic. 24

CNS Drugs 26
syndrome. Am J Hosp Palliat Care 29
J Craniofac Surg 22

.
long-term follow-up. Paediatr Anaesth 23

Anesth
Analg 100
J Support Oncol 3
accidental dural puncture--a randomised controlled trial. Anaesthesia 69
BMJ 325
Guidelines for all Healthcare Professionals in the Diagnosis and
J Opioid Manag 8
Paediatr Anaesth 22
30
sickle-cell disease. Diving Hyperb Med 42
J Dent Res 85
Int J Surg 11
12
urban teaching hospital. Anesth Analg 94
Lancet 375
J Neurol 245
puncture headaches. Neurology 57
around a skin burn injury and increase pressure pain thresholds. Acta Anaesthesiol Scand 51
Anaesthesia 62
compression. Health Technol Assess 17
J Can Dent Assoc 69
concomitant migraine and restless legs syndrome? 3.
Anesth Analg 103
Pain 111
J Spinal Cord Med 25
Anaesthesia 64
discharge? A pilot study. 38
postcraniotomy pain. Acta Anaesthesiol Scand 43

J
Pain Symptom Manage 23
Clin J Oncol Nurs 18
injury. Arch Phys Med Rehabil 91

39
8:
Headache
Anesth Analg
94

Headache 48
Curr Opin
Anaesthesiol 21
Can J Anaesth 54
Br J Gen Pract 50
Ann
Pharmacother 49
Med 29
35
Cephalalgia 34
Br J Surg 77
Anesthesiology 76
Paediatr Anaesth 18

42
18
Arch Orthop Trauma Surg 130

J Neurol
260

Clin J
Pain 25
Pain 133
controlled trial in Taiwan. 50
Anesth Analg 109
32
Arch Fam Med 9
Int J Pediatr Otorhinolaryngol 72
updates. Am J Hosp Palliat Care 29
Ann Hematol 93

Pak J
Pharm Sci 27
10
Am J Hematol 82
pack therapy with no ice therapy following third molar surgery. Int J Oral Maxillofac Surg 34
Lancet Neurol 7
AIDS 24
J Burn Care Res 28
Lancet 367
Clin Nutr
29
14
J Palliat Med 13
59
Cochrane Database
Syst Rev 1
Cochrane Database
Syst Rev 3
J
Neurosurg Anesthesiol 14
Anesth Analg 92
trial. Neurology 56
Medicine Today 1
Aust Dent J 37
Neurol 15
Br J Cancer 99
cancer. Acta Anaesthesiol Scand 53

in cancer. Curr Med Res Opin 26
Colorectal Dis 14
26
Pain 136
Pain 152
Mult Scler 16

8:
Haemophilia 7

17
Phytomedicine 8
meta-analysis. CNS Drugs 25
Crit Care
16
Medsurg Nurs 23
Med Australas 25
center. J Urban Health 88
ambulance paramedics. Prehosp Disaster Med 12

Cochrane Database
Syst Rev 3
burn pain. Cochrane Database Syst Rev 6
procedures: an Australian case series. 11
Burns 37
18
Anaesthesia 69
Int J Clin Pract

54
Pain Med
Pain Med
J Pain 11
J Trauma Acute Care Surg 73
Jama 289
Headache 54
23
24
the literature. 39
Clin J Pain 29
Pharmacotherapy 15
Anesth Analg 104
Anesth Analg 112
Ann Intern Med 125

Cancer Pain Relief: with a Guide to Opioid Availability
Cochrane
Heart 95
Anesthesiology 103
36
Pain Physician 15
day discharge. Anesthesiology 100
Anesthesiology 98
Br J Anaesth
107
BMJ 322
Pain 135
Obstet Gynecol 118
17
J Am Coll
Radiol 8
247

Burns 36
330
Clin Infect Dis 22
Ann Surg Oncol 21
nalbuphine dosing regimens. 21

migraine headache. Can J Neurol Sci 40
21

Acta
Anaesthesiol Sin 32
J Neurosurg Anesthesiol
26
21
pain management protocol. Burns 39
fractures. Am J Surg 207
crisis. Pediatrics 93
Neurology 81
8:
BJU Int 108

Arch Trauma Res 1
Urology 72
Arch Gynecol Obstet 285

Anesthesiol Clin 30
J Neurosurg Sci 56
38
4
Br J Anaesth 111
2014.
Pain 63
23
management of breakthrough cancer pain episodes. J Pain Symptom Manage 47

Cochrane
caused by thyroid tumor spinal metastases. 22
Burns 39
12
meta-analysis. Pain Pract 14
clinical trials. Pain Med 14

Cochrane Database
Syst Rev 2
dysmenorrhoea. BJOG 112

Am J Pediatr Hematol Oncol 14
Burns 36
Anaesthesiol
Intensive Ther 44
9. THE PAEDIATRIC PATIENT
9:
THE PAEDIATRIC PATIENT
9.1 Developmental neurobiology of pain
BS NR BS
BS
BS
BS
NR BS
BS BS
BS
in utero
NR in utero
Level IV
NR
Slater
Level IV
Level IV
Level IV
NR
NR
descending inhibitory pathways and inhibitory networks in the dorsal horn are not fully
NR
Level IV Level IV
NR
NR PK PK NR
NR
NR
NR NR NR
NR
Key messages
S
Level IV
S Level IV
9.2 Consequences of early pain and injury

9.2.1 Early neurodevelopmental consequences
NR
Level III-2 NR
Level IV
NR
Level IV
9:
outcomes.

Level IV
Level IV
Level III-3
Level IV
Level III-2
Level III-3
9.2.2 Longer term consequences of early pain and injury
NR
BS BS
Level III-2
Level IV
Level IV
Level III-2
Level III-2
Level III-2
Level III-2
Level III-2
uncertain.
Level III-2
Level III-2
Level III-2
Level III-2
Level IV
Key messages
S
Level III-2
N Level III-2
N Level III-2
9.3 Paediatric pain assessment

Pain assessment
NR
Level IV
Level IV Level IV
Level IV Level IV
Level IV
NR GL
self-report is desirable but it is not always possible as their understanding of pain and
NR
9:
9.3.1 Pain assessment in neonates

NR
NR NR
9.3.1.1 Physiological measures
NR
NR
NR NR
Level IV
Level IV
Level IV SR
Level IV
Level IV
Level IV
Level IV
Level IV
Level IV
Level II
Level IV Level IV
Level IV
9.3.1.2 Behavioural measures
NR
Level IV
Level IV
Level IV
Level IV
Level IV Level IV
Level IV SR
Level IV
Level IV
Level IV)
Level III-3
Level IV
Level IV SR
NR
NR NR NR
•
•
Level IV
Level IV
9.3.2 Observational and behavioural measures in infants and children
NR
NR NR but a wider range
NR Level IV SR
NR NR NR NR
Level III-2 .
9:
NR Level IV SR

NR
•
•
•
•
9.3.3 Self-report in children and adolescents
NR
NR
NR Level IV
Level IV SR
Level IV
NR NR
Level III-2
NR
Level III-1 SR NR NR
NR NR
Level IV SR
among these but its use of smiling and crying anchor faces may lead to confounding with
Level III-1
Level IV
Level IV
Level IV
NR
•
•
•
Level IV
Level IV
NR
NR Level IV Page
Level IV SR
Level IV
NR
NR Level IV
NR
9.3.4 Children with cognitive impairment or intellectual disability
NR
NR
Level III-2

Level III-3
Level IV
NR
Level IV Level IV
NR
Level IV
Level IV
9:
Level IV

NR
Level IV
Key messages
S Level IV
S Level IV
opinion.
Pain assessment and measurement are important components of paediatric pain
U
Numbers
are not
shown to
child
Note
Source
Copyright
Scale Score
Unidimensional
Brow bulge Presence or absence of
Procedural pain
Taut tongue
Pursing of lips
Tongue protrusion
Scale Score
PIPP Postmenstrual age Procedural pain

preterm and term
neonates
pain in term neonates

Brow bulge
postmenstrual age and
Nasolabial furrow are only applied if other
Neonatal Infant Pain Preterm and term

Cry
Procedural pain
Arms
Legs
State of arousal
Crying
Sleeplessness
N-PASS
Procedural pain
responses if sedated Persistent pain
treatment
Persistent pain
Quality of sleep
Quality of contact with
nurses
Consolability
9:
Scale Score
Alertness

Prolonged pain
distress
Acute discomfort
) Procedural Pain
Nonintubated but face not
Note: Further details available in
Scale Score
Cry
Procedural pain
Touch
Young children
Legs
Cry
Consolability
Alertness Newborn to
adolescent
paediatric
Post cardiac
surgery in term
Further details available in Howard 2008a and Chorney 2014

Scale
Poker Chip Tool
Neutral anchors
faces
to tears
procedural pain
Coloured Analogue
Scale
Note: Further details available in Howard 2008a and von Baeyer 2014
Scale Score
NCCPC-PV
Vocal
Social
Body and limbs child not necessary
Physiological
PPP
Pain
Legs
Cry
Consolability
indicators superimposed
Note: Further details available in Valkenburg 2010 and Chorney 2014

9:
9.4 Analgesic agents

9.4.1 Paracetamol
NR
NR
NR
Level I
surgeries.
Level II
Level II,
Level II
Level II
Level II,
• Level II
•
Level II
• mg mg
Level III-1
•
Level II
•
Level II
•
Level II
•
Level II
•
Level I
9.4.1.2 Pharmacokinetics and pharmacodynamics
NR
PK
Level II, Level II
Level II
Clearance is reduced in neonates and increases with age to reach adult rates during
PK
PK NR PK
Level III-1 PK
NR
mg
kg) PK
IV dose Reference
dose dose
Nil data
proposed
proposed Note: Limited data in
PK
NR
Nil data
PK
9:
IV dose Reference
dose dose

Level III-3
PK PK
load NR
PK
Level IV
NR PK
PK
PK
for acute
9.4.1.3 Adverse effects and safety
Overall safety
Level IV SR
NR Allegaert
PK NR
Hepatotoxity
Level IV
Level IV
NR
Level IV
Level IV SR
Asthma
increased de novo
NR
Level III-3 SR,
Level III-3 SR
Level III-3 SR
Level III-2 SR
Level III-2
unclear.
Key messages
S Level I
N Level IV
SR
opinion.
N
9.4.2 Nonselective NSAIDs
Level IV
9.4.2.1 Pharmacokinetics and pharmacodynamics
NR
PK PK
Level II
PK PK
9:
onset when assessing outcomes.

PK
PK
Level II
PK
PK
NR
PK
PK
NR
NR
NR
Level II
Level II Level II, Level II,
Level I
Level I
Level I
surgery
Standing
Level I
Level II
Level II,
Level II,
Level II,
Level II
Level II,
Level II,
Level I,
Level II
NR
NSAIDS and reduction of postoperative nausea and vomiting
Level I,
SR Level I
Level I
Level I
Overall safety
In large series of children with febrile illnesses
Level II
Level II
Level IV SR
Anaphylaxis and allergy
Level II
fatal from study data and nine nonfatal from case reports Level IV
Level IV
9:
NR
Aspirin or NSAID-exacerbated respiratory disease
CR
Level III-3
Level II
Platelets and bleeding
Level III-1
Level I
been small to date and results remain contradictory. Bleeding risk has been the subject
SR Level III-2
Level I
Level I
Lewis
Level I
Adverse gastrointestinal effects
Level IV
Level II
Level I
Renal and vascular effects
PK
Level IV NR Andreoli
NR NR
NR
Level II
acute kidney injury with ibuprofen alone that is higher when paracetamol is coprescribed
Level IV
NR
PK NR NR
Level I
Level III-2 NR
Bone healing
spinal fusion surgery.

Local necrosis following intramuscular injection
Standing
Level IV
Key messages
S Level I
S Level I
N Level I
age S Level II
N Level III-
3
opinion.
U
N
9:
9.4.3 Coxibs

agents in children remains poor.
9.4.3.1 Pharmacokinetics
PK
in vitro
PK
Level II
Level II Level II
Level III-3
Level II
Level II
Level III-2
Level IV
Level II,
Overall safety
PK Level III-2
Safety in overdose
Level IV
NSAID-exacerbated respiratory disease, bronchospasm, allergy and anaphylaxis
Quiralte
Level IV
Level IV
Level IV
Bleeding
Level II
Level I
Level II,
Gastrointestinal
years
years Level III-2
Renal
Level III-2
Key message
opinion.
N
NR PK
NR
renal impairment
Level IV Level IV
9.4.4.1 Pharmacogenomics

NR Level IV
NR
Level IV NR Chidambaran
Level IV
Level IV
9:
NR

9.4.4.2 Medication prescribing errors
Level IV
Level IV
Level IV
9.4.4.3 Morphine
standard comparator or rescue agent in analgesic trials.

Pharmacokinetics and pharmacodynamics
PK PK
Bouwmeester
Level II
Level IV
The risk of respiratory depression is reduced when infusions are targeted to plasma morphine
NR
Level I
Level II
9.4.4.4 Fentanyl
potent mu-opioid agonist.

Pharmacokinetics
NR
NR
NR
GL Level III-2
Level II Level I,
Level II Level II
Level II Level II
Level III-3
GL
NR
Level IV SR
Level IV
Level III-3
Level III-2
Level IV SR
Level IV SR
Level II, ; Level II Level IV
Adverse effects
at similar rates to other opioids or may be increased.
Level III-2 NR NR
Level III-2
CR
CR
NR
NR
9.4.4.5 Codeine
prescribing of this opioid prodrug.

Pharmacokinetics
PK
Level IV
9:
Pharmacogenomics and adverse effects
Zhou

NR NR
NR
Level II PK
Level IV
Level IV; Level IV; Level IV Level IV
CR Level IV, Level IV

Level IV
GL
NR
Level II
NR
Level II
Level II
Level II
Level II
Level II
Level II,
NR
Level IV Teo
Level IV
9.4.4.6 Oxycodone
Pharmacokinetics and pharmacogenomics
PK
PK
PK
PK
NR
Level II
Level II,
Level IV
Level IV Level II
9.4.4.7 Other opioids
GL
Hydromorphone
Level I
Level IV
Hydrocodone
Level II
CR
Methadone
Level II
Level IV
Buprenorphine
Level IV SR
n
Level IV
Sufentanil
Level IV
Diamorphine (diacetylmorphine, heroin)
Level IV
Level II Level IV
9:
Level III-2 Level III-3 Level IV

Level III-2
9.4.4.8 Tramadol
Pharmacokinetics and pharmacogenomics
PK
Level III-3 SR
PK
PK PK
NR
PK
NR
Systemic administration
PK NR
Level II Level II
Level III-
3 SR
Level II
Level II
Level II,
Level II oral
Level II
Level II
Level II
Level II
Level II
Level II
Level II
Neuraxial administration
NR
Level I mg
Level II
Level II
Level II
Level II Level II
Level II Atef
Level II
Level II
Level II
Level II
Level II,
Level II,
Level II
Level II
Level II
Adverse effects
NR
Level IV
Level IV
Level II
9:
Level IV
CR

Level IV
Level IV
CR
CR CR
CR
NR
NR
CR
administered cannot be determined and raises the issue of dosing confusion with the
Key messages
Opioids
S Level II
S Level IV
N
Level IV
N Level IV
opinion.
N
Tramadol
N Level II).
opinion.
N
9.4.5 Ketamine
9.4.5.1 Pharmacodynamics and pharmacokinetics in children
PK PK
PK
EH
PK
NR
Level II
Perioperative use
Level I
Level I
9:
Level I
Two tonsillectomy studies not included in these meta-analyses had similar conclusions.
Level II
Level III-1
Postoperative infusion
Level II
Level II
Level II
Level II
Palmer
NR
Acute pain and relevant pharmacokinetics
Level IV
Level IV CR Level IV
Level IV
Level IV
Level IV
Level IV
Level IV
PK
Level I
Level II
Level I
Level II
Level II
Level IV Level IV
analgesic doses or infusions.
Neurotoxicity
NR NR
NR BS
NR NR
Key messages
N
Level I
N Level I
N Level I
N Level II
opinion.
N
9.4.6 Alpha-2-delta ligands (gabapentin/pregabalin)
9:
Level II

9.4.7 Alpha-2 adrenergic agonists
GL Level
III-2 NR
Level IV SR NR
NR
9.4.7.1 Clonidine
NR
NR NR
Level I
Level I,
Level I,
NR
Level II
Pharmacokinetics
PK
9.4.7.2 Dexmedetomidine
NR NR
Level I
Level I
Level II
Level II
Level II
Level III-2
Level II,
CR
Pharmacokinetics
PK
NR; Level III-2

NR NR
NR NR
Level I
Level II
Level II
Level II,
Level I
Level I
9:
NR NR
Key messages
(N) (Level I
(N) Level I
N Level I
N Level II
opinion.
N
9.4.8 Corticosteroids
Level I
Level II
Level II,
Level I
. A sub-analysis to
Level II
Level I Level I
Level I SR Level III-1,
SR Level III-1,
Key messages
S Level I
Q Level I
N Level I
9.5 Opioid infusions and PCA
Level IV Level II
GL
9.5.1 Opioid infusions
Level III-2
Level II, Level II

Level II
Level II
Level IV PK
GL
Level II Level II
Level II Level IV
Anand
Level II,
GL
Level II
9.5.1.1 Adverse effects, complications and outcomes
Level IV
9:
Anand

Level II
Level I
Level IV
Level IV
Level II Level II
Level III-2
9.5.1.2 Iatrogenic opioid dependence in hospitalised children
and management of withdrawal is important to reduce physiological disturbance. This is

Level IV; NR
Level IV
Level III-2
Level II
Level III-3
Level IV
Level III-3; Level IV; Level III-3 Level III-3
Level II,
Level III-3
SR
Level II
Level III-3
Level III-1
Level IV
Level IV
Level IV Level IV
Benner
NR
CR
9.5.2.1 PCA prescription
Level IV
Level IV
Level II
Level IV NR
Level I
be assessed. Although use of a background infusion was associated with increased sleep
Level IV
Level IV
NR
Level III-1
Level II
GL
Level II
Level II
Level IV
Level IV
Level III-2
Level IV
not lead to harm were also reported.
Level IV
9:
Level IV
9.5.3 Nurse-controlled analgesia
Level IV
Level III-2
Level II
Level IV
Level II
Level II
Level III-2)
Level IV Level IV
Level IV)
Level IV
Level IV)
Level IV
9.5.4 PCA by proxy
Level IV
NR
Level IV
Level IV
Level IV
Level III-3
Level IV
Level III-3
Level IV
9.5.5 Overall safety of parenteral opioid use in children
Level IV
Level IV)
Level IV
Key messages
Q Level I
N Level III-3
U Level II
U Level III-1
S Level III-3
S Level III-2
N Level III-2
N Level III-3
opinion.
W
9:
9.6 Regional analgesia

Level IV
ongoing.
9.6.1 Continuous and single-injection peripheral nerve blocks
Level IV
Level IV Level IV NR Level IV
NR Level IV
Level IV
9.6.1.1 Continuous peripheral nerve blocks

Level IV
Level IV Level IV
in situ
Level IV
Level IV
9.6.1.2 Safety and complications of peripheral nerve blocks
Level IV Level IV
Level IV). The PNBs in these audits were mostly performed under
Level IV Level IV
Level IV Level IV
Level IV
Level IV Level IV Level IV Polaner

Level IV Level IV
Level IV
Level IV Level IV
Compartment syndrome
There were three case reports of compartment syndrome in adolescents that was not masked
CR CR CR
injury or surgery.
9.6.1.3 Ultrasound guidance impact on safety and success
Level I
,
Lower limb blocks
Level IV Level II
Level IV
Level II
Level IV
Level IV
Level II
Upper limb blocks

Level IV Level IV
Level II
Level II Level IV Ponde
Level II Level II Level IV
Level IV Level IV
Level I
Level II
Paravertebral blocks
Level IV
Level IV
Level IV Level IV Qi
Level II
Level IV
Level III-3)
Level II
9:
Level III-2

Transversus abdominis plane blocks
Level IV
Level II
Level II
Level II
Level II
Level IV
Level IV
Circumcision
Level I
Level II
Level I
Level II
Level I
Level II Naja
Level II
GL
GL
for neonatal circumcision.
Inguinal and umbilical surgery
has been found with wound
Level II
Level II
Level II =
Level IV
Level II =
Level II
Level IV
Level II
Level II
Tonsillectomy
trials is challenged
Level I,
Level II
Level II,
Level II
Level II Level II
Level II
Level II Level II
Level II
Level II,
Level III-3
Head and neck surgery
Pardey
Level IV Level IV
Level IV) Level III-3
Level II
Level II
Level II
Level III-3
Level II Level II
9:
Level II

Level II
Level II

Level II
Level II
Level II
Level III-2
Level II
st
permanent
Level II
Level II
Level II
Level III-2
Level II
9.6.2 Neuraxial blocks
NR
9.6.2.1 Caudal analgesia
Level IV
Level IV Level IV
Level IV Level IV
Level IV Level IV
Level II Level II
Level II Level II
Level II
Yao
Level II
age
Study Level IV
Study Level IV
Abdominal New formula
height assessed by
response to painful
successfully completed
Study Level II
Inguinal
Study Level II
Vs
9:
age
Study Level IV
Subumbilical surgery:
and inguinal reached:
was lower than studies

young children.
Study Level II
Study Level II
Study Level III-2
analgesic rescue.
Study Level III-2
inguinal
abdominal
Caudal adjuvants
NR
Opioids
Level IV Level II
Level II
Level II
NR
Constant
Level II Level II
Level II Level II
Adrenaline (epinephrine)
Level I
Level IV
PK
Alpha-2 agonists
Level I
Level I
Level I
Level I
Level II
Level II
PK
Level II
Level II Level II
9:
Level II

Dexamethasone
Level II
Level II
Ketamine
Level I
Level I
Level I
Level I
A subanalysis of S-ketamine added to caudal anaesthesia was performed showing similar
Level I
in vitro BS NR
Tramadol, neostigmine and midazolam
Level I
Level II
Level I mcg
mcg mcg
Level II
Level II
Level II
Level II
9.6.2.2 Epidural analgesia
Level IV
Level IV Level IV
Level IV
Level IV SR
Level IV Level IV
Local anaesthetics
Level IV Level IV Level IV; Level IV
Level II
Level III-3 SR
Level II
detected.
Level IV
Level IV
Level II
Level IV
Level IV
Epidural opioids alone
Level II
Level II
Level II
Level II
Level II
Level II
Local anaesthetic and opioid or other adjuvant in combination

Level II
Level II
Level II,
Level II
Level II
9:
9.6.2.3 Outcomes

Level II
Level II
Level II
less marked during epidural analgesia compared with systemic opioids but the degree of
Level II
Level IV Level IV
Level IV Level IV
NR
Level I
Level II
Level II
9.6.2.4 Complications
Overall complications
The safety of performing paediatric regional anaesthesia under general anaesthesia or deep
Level IV Level IV Level IV Level IV Level IV

Level IV
Level IV
Level IV Level IV
Level IV
blocks Level IV)
Level IV
epidurals Level IV
Level III-2
Study
Denominator Years audited
LAST Dural tap,

cardiac arrests PDPH
PONS Drug error NS
Death, cardiac Pressure sore NS

arrest
Bleeding NS Compartment NS
syndrome
LAST Dural tap,

PDPH, blood
patch
PONS
to erosion by
patch
Death,cardio- Drug error NS

respiratory
Bleeding Pressure sore NS

Compartment NS
syndrome
LAST Dural tap,

PDPH,
total spinal
anaesthesia anaesthesia
PONS Drug error
infant
Death, cardio- Pressure sore NS
respiratory
syndrome
9:

LAST PDPH, blood
patch
PONS Drug error
Death, cardio- Pressure sore

respiratory
Bleeding Compartment
syndrome
LAST Dural tap,

PDPH
PONS Drug error NS
Death, cardio- Pressure sore NS
respiratory morphine
syndrome
LAST Dural tap,

PDPH,
intrathecal
placement
unrecognised
PONS Drug error
Death, cardio- Pressure sore

respiratory
Bleeding Compartment
syndrome
Notes:
Local anaesthetic systemic toxicity
remains a high-risk
Level IV
Level IV
Level III-2
Level II,
Level IV Level IV
Ludot
CR
GL GL
Postoperative neurological symptoms
Level IV
an immobile child outweighing the risk of performing regional anaesthesia under general
anaesthesia in children.
Level IV
Level IV Level IV
Level IV
Care of insensate body regions is important as prolonged block and immobility may result in
CR
Deaths associated with epidural use

Level IV
Level IV
CR
Bleeding/epidural haematoma
Level IV
Level IV
9:
Level IV

CR
Dural puncture
Infection
Staphylococcus aureus the most
Level IV
Level IV
Level IV
Level IV Level IV
Level IV
Level IV).
Compartment syndrome and pressure sores

Compartment syndrome
Level IV
Level IV
Level IV
NR
9.6.2.5 Intrathecal opioids
Level II
Level II
Level II
Level II
Level II
9.6.2.6 Regional analgesia use in paediatric spinal fusion
Level II mcg Level III-3
Level III-3
Level III-2
Level I
Level II
Level IV
Level II
approach Level II Level III-2
Level II
Level III-3
Level III-3
9.6.3 Topical therapies
9.6.3.1 Tonsillectomy
Level I,
Level II
Level II
9.6.3.2 Acute otitis media
Level I
Level II
Level I
9.6.3.3 Acute mouth ulceration
Level II
9.6.3.4 Nasogastric tube insertion
Key messages
U Level I
U Level I
N
Level I
N Level I
9:
N Level

S Level I U Level II
N Level I
N Level II
U Level II
U Level II
N Level III-3 SR
U Level II
U Level II
S Level III-2
S Level III-2
S Level IV
N Level III-2
N Level IV
N Level IV
S Level IV
9.7 Management of procedural pain in children
NR NR
Taddio
Level II Level IV Level IV
NR NR
Level IV; Level IV Level IV

GL
NR
GL GL GL GL
GL
9.7.1 Procedural pain in the neonate
9.7.1.1 Blood sampling, skin puncture and intravenous cannulation
Different techniques of blood sampling
Level I
Level II
Topical local anaesthesia
Level I
Breastfeeding, supplemental breast milk and sweet solutions
Shah
Level I
Level III-1 SR
Level I Level I
Level I
Level II
Level I
repeated doses.
Opioids
Level I
9:
Combination intervention in neonates: pharmacological

Level II
Level II
Level II
Bueno
Level I
Nonpharmacological intervention alone and in combination
Level I
was superior to kangaroo care with sucrose and compared to either kangaroo care or sucrose
Level II
Level I
Level II
Level II
Level I ,
Level II,
Level II
Baba
Level II,
Level I,
9.7.1.2 Lumbar puncture
Level IV
Level IV
Level IV
NR
NR
Level II
9.7.1.3 Urine sampling
Level II,
Level II,
Level II,
Level II
9.7.1.4 Ocular examination for retinopathy of prematurity
Level IV
Level I
Level I Level II
Level I
Inhaled N
Level II
Level I
9.7.2 Procedural pain in infants and older children
9.7.2.1 Venipuncture and intravenous cannulation
NR
Level I
Level I
Level I
Level I
Level II
Level II Level I
Level I
n
9:
Level II
Level I
Nitrous oxide
N
Level IV SR
Level II,
Level I
Level IV SR
Combination pharmacological intervention
Level II,
Sweet-tasting solutions in older children
Level I ,
Nonpharmacological intervention
Level I,
Level II
o
Level I,
Level III-2
Level II
o
Level II,
assessment in children.
Level II
Level II
9.7.2.2 Lumbar puncture and bone marrow aspiration
NR
Level IV
analgesia with N NR
Topical local anaesthesia and nitrous oxide (alone or in combination)
Level III-1
Level II,
Level IV SR
Level IV Level IV
Some studies specify N
Level IV
Level IV
Fentanyl alone
Level II
Single or double agent sedation vs general anaesthesia
Level IV
Level III-3
Level IV SR,
Level II,
Level II
Level II
Level II
Level II
Reduction of postdural puncture headache incidence
Level III-2
Level II
Level III-2
9:
Level III-3

9.7.2.3 Botulinum toxin (intramuscular) or steroid (intra-articular) injection
Level II
Level IV
Level IV
Level II
Level IV
joints.
9.7.2.4 Urethral catheterisation and micturating (voiding) cystourethrogram
Local anaesthesia — topical and installation
Level II Level II,
Level II
Level II,
Nitrous oxide
N
Level IV SR
Intranasal fentanyl alone
Level II
Level III-2
Level II,
9.7.2.5 Chest drain removal
Level III-2 SR
Level IV
Level III-3
mcg/kg IN has been used in children for
Level IV
Level IV
Level I
Level II, Level II
Babl
Level II
Ketamine
Level II,
Level II
9.7.2.7 Burns dressings
NR
Level III-2
Level IV
NR
Burn dressing types
Level I
Opioids
Level II,
Level II,
Level III-2
Level II,
Ketamine
Level III-1 mg mcg

Level IV
Level IV
9:
Level II
Dexmedetomidine
Level II
Level III-1
drawn as to the impact upon pain outcome.
Nonpharmacological intervention for burns dressings
Level II,
Level II, ; Level III-2 SR,
Level IV Level IV
Level IV
Level III-1
Level III-1
Level II
Level II
Level II
Nonpharmacological interventions for physiotherapy in burns rehabilitation
Level II
Level II,
Level II
9.7.3 Immunisation pain in infants and children
Level IV
Level IV Center for Pediatric
Taddio
Level III-1 SR,
Level I, Level II
Level I
9.7.3.2 Topical local anaesthesia
Level I SR
Level II
GL
9.7.3.3 Sweet solutions
Level I
Level II
Level I
9.7.3.4 Nonpharmacological intervention for immunisation
Physical interventions
Level III-1 SR Level III-1

SR
Level I
Level II
Level II
Psychological interventions
Level IV SR
y Level I
9:
Level I
Combination intervention
Level II
Level III-1 SR
Level II
Level II
9.7.4 Procedural pain management in the emergency department
GL
GL
9.7.4.1 Laceration repair
Level I
pain scores. The most widely used topical agent applied to paediatric wounds is currently
Level I
Level II,
Level II
Alternatives to suturing: tissue adhesives and hair apposition
Level I
Level II
Level II
o
Level I
Level I
Midazolam
Level II
Nitrous oxide and ketamine alone or in comparison

Inhaled N
Level I,
Level IV
n Level IV
GL
N
Level II
Level II
Level IV
Level IV
9.7.4.2 Fracture pain and reduction
Fracture pain
Opioids, tramadol and NSAIDs
Level IV SR
Level III-2
9:
Level III-3
Level III-3
Level II
Level II Level II
Level IV, Level III-3,

Level II
PK
Level II,
Level II
Level II,
Level II
Level II
Level II
Level II
Ketamine
Level IV Level IV CR Level IV
Level IV
NR
Level II
Level III-2)
Level IV SR
Closed fracture reduction
Level IV SR
Level IV Level IV
Level I Level IV GL
GL
GL GL
NR Level IV
Level I Level III-3
SR
Level II
Level II
Level III-3,
NR
Opioid/propofol and ketamine/propofol combinations
Level IV SR,
Level II Level II
PK
9.7.4.3 Psychological interventions
9:
9.7.5 Nonpharmacological strategies in children and adolescents

Level I
Level II
Level I
Level I
Level II
Level III-2 SR,
Level III-2 SR,
Level III-2 SR,
studies
Level I,
Level II
Level IV
GL
GL
GL
NR
Key messages
S Level I
S Level I
N Level I
N Level I
N Level II
N Level I
U Level I
S Level I
S Level I
Q Level I
S
Level I
N Level I
U Level II
N Level II
N
Level II
N Level III-2
N Level III-2
N Level IV
9:
opinion.

U
9.8 Acute pain in children with cancer

NR
Level IV
was updated in
GL
9.8.1 Cancer-related pain

9.8.1.1 Tumour-related pain
Level IV
NR
GL
NR
NR Level IV
Level IV
9.8.1.2 Pain in the terminal stages
Level IV
Level IV; Level IV
Level IV
Level IV Level IV
9.8.2 Procedure-related pain
Level IV Level IV
9.8.2.1 Lumbar punctures, bone marrow aspirations, blood sampling
9.8.2.2 Central venous port access
Level II
Level II,
Level II
Level III-2
9.8.3 Treatment-related pain
Level IV Level IV
9.8.3.1 Mucositis
Level IV NR
Level IV Level II
Level I
Level II
Level II
Level II
Level IV
Level IV
Level IV
Level III-3
Level IV
Level I
9.8.3.2 Neuropathic pain
Neuropathic pain can occur acutely secondary to chemotherapy for childhood leukaemia
Level IV
Level IV
9.8.3.3 Postoperative pain
9:
Level IV

Level IV
Level IV
Level IV
Key messages
S Level I
N Level I
U Level II
N Level II
opinion.
9.9 Paediatric migraine
Sheridan
NR
GL GL
GL GL GL Triptan trials in
GL
Level IV SR
9.9.1 Single pharmacological therapies
Level I,
Level I,
Level I,
Level I,
Level I,
Level I,
Level I
Barnes Level I
Level I,
Level I Level I,
Level I,
Level I,
Level I
Level II
Level I
9.9.2 Combination pharmacological therapies
Level II in recurrent
Level IV
Level III-3
9.9.3 Nonpharmacological therapies
Level I,
9:
Key messages

N Level I
N Level I
opinion.
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Anesth Analg 102
and intranasal diamorphine in children. Arch Dis Child 94
Br J Anaesth 112
Burns 38
Ambul Pediatr 8
58
with sickle cell pain crisis. Am J Hematol 83
impairment. Pain 111

Paediatr Drugs 12
13
Pediatrics 120
analgesia in children. Anesth Analg 88
Paediatr Anaesth 22
research. J Pediatr Nurs 27
management of orthopedic injury-related pain in children. 23
Ann Fam Med 8
catheters in children. Anesth Analg 86
brain. Acta Paediatr 99
Anesth Analg 90
Pediatrics 118
and reliability. Paediatr Anaesth 5
children. Clin Pharmacokinet 50
J Clin Pharmacol 52
Anesth Analg 101
children. Br J Clin Pharmacol 70
HSS J 8
Paediatr Anaesth 8
Paediatr Anaesth 15
Pediatr Res
65
Cochrane
Database Syst Rev 1
department. 22
Surgeon
1
J Pediatr Nurs 25
9:
epidural infusion. Anesth Analg 84

Paediatr Anaesth 22
J Spinal Disord Tech 23
Pediatrics 126
Neonatal Netw 12
44
28
26
Anesthesiology 99
Pediatrics 109
clinical trial. JAMA 273
old. Pediatrics 104
Paediatr Anaesth 23
the pediatric emergency department. Headache 53
analgesic therapy. 220

J Clin
Pharmacol 52
Pain 152
J Neurosci 31
rare case reports. Paediatr Anaesth 22
Int J
Nurs Stud 50
Clin J Pain 23
Pain 142
comparison with paracetamol. Paediatr Drugs 3
16
appendectomy in children. Paediatr Anaesth 23
their parents. Acta Paediatr 88
Pediatr Hematol Oncol 17
Pain 68
Paediatr Anaesth 17
Anesth Analg
119
Paediatr
Anaesth 19
compliance with pain management guidelines. 96

Clin
Pharmacokinet 52
epidural infusions with and without fentanyl. Acta Anaesthesiol Scand 45
Paediatr Anaesth 18
Anesth Analg 106
Pediatrics
118
Paediatr Anaesth 21
Anesth Analg 86
Anesth Analg 104
Pain 88
28
morbidity following childhood tonsillectomy. Otolaryngol Head Neck Surg 147
Paediatr Anaesth 13
23
Pediatrics 126
Can Fam Physician 53
23
Anesth Pain Med 4
J Anesth 28
Paediatr Anaesth 16
Paediatr Anaesth 16
following spine fusion surgery. Paediatr Anaesth 11
trial. 97
Clin Pharmacol Ther
60
infant. Pediatr Neurol 44

9:
children. Anaesthesia 59

98
Acta Paediatr 103
J Opioid Manag 10
Anesth Analg 100
series. 24
Pain Res Manag 16
acute treatment of migraine in adolescents. Headache 51
J Opioid Manag 8
children following neurosurgery. Paediatr Anaesth 10
Anaesthesia 37
Pain 64
J Pain 9
Ann Surg 254
Can J Anaesth 59
28
Pain 150
Reg Anesth 22
Br J Anaesth 71
54
Material Safety Data Sheet
Anesth Analg
104
preterm infants. J Pediatr 145
Can J Anaesth 59
young children. Pediatr Nurs 23
Can J Anaesth 60
pharmacology. Paediatr Anaesth 21
Anesth Analg 114
Anesth Analg 82
Adv Neonatal Care 11
fusions in adolescent idiopathic scoliosis. 34
for preterm newborns. 95

with burn injuries. Burns 36
14
J Craniofac Surg 22
pediatric pain. 13
diagnosed malignancy. Pain 29
kidney injury in children. J Pediatr 162
J Opioid Manag 6
paracetamol in children. Br J Anaesth 108
tonsillectomy. Laryngoscope 110
Anesth Analg 91
Anesth Analg 113
Pediatrics 129
Paediatr Anaesth 20
Pain 128
tonsillectomy. Paediatr Anaesth 24
undergoing burns dressing changes: a randomised controlled trial. Burns 34
responses in school age children. Aust J Adv Nurs 24
Acta Biomed
80
J Pediatr
Health Care 25
25
Paediatr Anaesth 12
88
Reg
Anesth Pain Med 28
Pharmacol Sci 15
Clin J Pain 23
circumcision in children: a randomised controlled trial. Anaesthesia 66
Anesthesiology 103
9:
hypospadias in children. Anesth Analg 117
9

in pediatric cardiac surgery. Ann Card Anaesth 16
Arch Dis Child
90
Reg
Anesth Pain Med 35
27
Anesth Analg
110
J Med Toxicol 5
Clin Perinatol
40
Arch Dis Child 98

Paediatr Anaesth
24
reports. Br J Anaesth 110
post-tonsillectomy pain: a randomised double-blind study. Anaesthesia 63

Pain 153
J Pediatr Surg 48
Paediatr Anaesth 24
Ther Clin Risk Manag 10
Prehosp Disaster Med 28
Burns 38
Paediatr Anaesth 21
birth weight infants. Cochrane Database Syst Rev 4
controlled trial. Paediatr Anaesth 24
Anesthesiology 117
Burns 38
Drug Saf 29
Pediatrics 135
Bull Cancer 98
J Burn Care Res 27
Paediatr Anaesth 15
Dev Psychobiol 51
J Pain 13
Br J Anaesth 101
Oxford Textbook of
Paediatric Pain
teaching hospital. Anaesth Intensive Care 35
block in children. Anaesth Intensive Care 39

40
39
Anesth Analg 96

Paediatr Anaesth 18
burned adolescents. J Burn Care Res 31
Anesth Analg 92
Dan Med J 60
17
Cardiovasc Toxicol
15
Paediatr Anaesth 24
Paediatr Anaesth 9
Pediatrics 111
Pain 114
Paediatr Drugs 10
Acta Paediatr 87
Br J Anaesth 112
Br J Anaesth 88
procedural pain. Cochrane Database Syst Rev 10
BMJ 345

Paediatr
Anaesth 15
Anesth Analg 115
J Pediatr Urol 9
Anesth Analg 106
28
9:
Clin J Pain 28

42
Paediatr Anaesth 18
guidance. Ann Phys Rehabil Med 52
Nuss procedure. Reg Anesth Pain Med 39

17
Guideline Statement: Management of Procedure-related Pain in Neonates
Paediatr Anaesth 18
30
Paediatr Anaesth 17
24
infants during a painful procedure. Clin J Pain 29
adults and children with haemophilia. Haemophilia 12
J Pediatr
Orthop 32
30
28
Pediatrics 127
Can J Anaesth 49
infants and children. J Opioid Manag 8
inguinal hernia repair. Anaesthesia 62
tonsillectomy. Clin Otolaryngol 38
J Burn Care Rehabil

24
Pediatr Dent 33
36
in children with cancer pain. Support Care Cancer 15
adolescents with thoracic surgery: a placebo controlled double-blinded study. 11

Pediatr Surg Int 26
Anesth Analg 110
caudal block in pediatrics. Acta Anaesthesiol Scand 53
J Clin Anesth 21
management in children. Pharmacogenomics 15
30
Ann Allergy
Asthma Immunol 95
Ann Allergy
Asthma Immunol 94
8-year-old children. Pain 153
Br J Anaesth 106
pediatric spinal surgery. Paediatr Anaesth 18
Pediatrics 126
procedures in children. Pediatrics 95
Pediatrics 119
Pain Res Treat 2012
during physical therapy for pediatric burns. Burns 37
Br J Anaesth 107
Paediatr Anaesth 21
Paediatr Anaesth 23
25
Paediatr Drugs 9
Paediatr
Anaesth 15
15
undergoing adenotonsillectomy. Paediatr Anaesth 9
in paediatric cardiac surgery. Ann Card Anaesth 12
anaesthesia in paediatric strabismus surgery. 28
Int J
7
57
Cochrane
9:
success of procedure in term neonates. Arch Pediatr Adolesc Med 157

Clin
Ther 31
Cochrane
report of three cases. Anaesthesia 38
Arch Phys Med Rehabil

88
Laryngoscope 122
adenotonsillectomy. Paediatr Anaesth 14
21
department. Headache 54
J Trauma Acute Care Surg

76
89
Anaesthesia 55
tonsillectomy analgesia in children. J Coll Physicians Surg Pak 23
16
J Paediatr
Child Health 44
Am J Phys Med Rehabil
89
7
PLoS
Med 5
J Neurosci 26
a randomised controlled trial. Lancet 376
Pediatr Rheumatol Online J 12
Drugs 73
Pain 150
J Pediatr Nurs 22
anaesthesia. Can J Anaesth 42

Paediatr Anaesth 21

Can J Nurs Res 39
Clin J
Pain 12
Clin J Pain 26
at risk for neurological impairment. Pain 127

Pain
105
feasibility. Clin J Pain 30
and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents. Pain
125
24
J Child Adolesc Psychopharmacol 21
Am J Psychiatry 163
cases. Anesth Analg 80
J Pediatr Surg 49
children. 24
Spine 30
JAMA Pediatr 167
Anesth Analg 98
Anesth Analg 94
tonsillectomy. Clin J Pain 26

25
and caudal analgesia. Clin J Pain 24

Crit Care Clin 22
boys. Lancet 345
controlled trials. Clin Ther 31
JAMA 295
treatment of acute pain in neonates. Pediatrics 101
Pain 144
Pediatrics 127
analysis. Paediatr Anaesth 20

9:
Reg Anesth Pain Med
39

Ann Plast Surg 63
J Burn Care Res 30

Anaesth
Intensive Care 30
Pain Res Manag

13
Paediatr
Anaesth 23
Am J
Hosp Palliat Care .

Arch Dis Child 94
39
Paediatr Anaesth 16
Medicines Safety Update Volume 6 Number 4, August 2015: Tramadol oral drops - not for children under
Paediatr Anaesth 20
Semin Fetal
Neonatal Med 10
Pediatr Crit
Care Med 8
29
31
Pediatrics 90
60
tool in children. J Pediatr Oncol Nurs 25
intensity in children. Pediatrics 126
Anesth Prog 56
and adolescents--a meta-analysis. Cephalalgia 26
assessment. Int J Qual Health Care 14

Paediatr Anaesth 23
Paediatr Anaesth 22
hemophilic arthropathy. Blood 107
Anesth Analg 98
Anesth Analg 94
preliminary report. 28
Pediatrics 132
Paediatr Anaesth 23
Int J Nurs
Stud 44
Int J Pediatr
Otorhinolaryngol 77
children and adolescents. Cochrane Database Syst Rev 10
29
J Clin Anesth 23
children. J Clin Pharmacol 52
Pain 152
Dev Disabil Res Rev 16
Br J Anaesth 108
morphine for post-tonsillectomy pain control. J Otolaryngol 36
Burns 37
Arch Dis Child
96
Paediatr Anaesth 14
Pain 98
Pain 84
Clin J Pain 25
Can J Anaesth 50
Paediatr Anaesth 19
of the pediatric pain item bank. J Pain 11
Pediatrics 116
morphine in children. Pharmacogenomics 15
Anesth Analg 95
table of contents.
Br
J Anaesth 112
hospital. Reg Anesth 17
age. Br J Anaesth 100

Pain
153
Paediatr Anaesth 22
Spine J 3
Anesth
Analg 107

9:
Pain Res
Manag 11
Oxford Textbook of Paediatric

Pain
scales for preschool-age children. J Pain 14
13
Pain 127
Pain 143
Pharmgenomics
Pers Med 5
Diabetes Technol Ther 15
Anesth Analg
112

Br J Anaesth 101
Clin Perinatol 40
Pain 141
Anesthesiology 113
Anesth Analg 115
J Clin Pharmacol 54
Cochrane Database
Syst Rev 3
29
Paediatr Anaesth 14
Anesth Analg 106
children. Arch Pediatr Adolesc Med 152
analgesia. Clin J Pain 9
the literature. 39
of primary nociceptors. Neuron 82
Paediatr Anaesth 21
.
Nat Rev Neurosci 2
the mother. 65
Acta Paediatr 100

Br J Anaesth 86
Paediatr Anaesth 13
Br J Anaesth 89
Br J Anaesth 97
children. Br J Anaesth 95
Br J Anaesth 97
Paediatr Anaesth 21
analgesia. Paediatr Anaesth 8
Br J Anaesth 70
Pediatr Nurs 14
Can J Anaesth 60
Anaesthesia 65
Paediatr Anaesth 23
BMC Pediatr 11: 87.

J Neurosci Methods 205
Pediatr Rev 34
Paediatr Anaesth 17
Br J Anaesth 110
Anaesthesia 64
Pharmacol 70
Pediatrics :
disease-related pain: a case series. Clin J Pain 26
J Pain 8
Clin Pharmacokinet
48
Clin
Pharmacokinet 48
Dev Med Child Neurol 50
Br J Anaesth 93
Pediatr Neurol 48
10. OTHER SPECIFIC PATIENT GROUPS
10:
OTHER SPECIFIC PATIENT GROUPS
10.1 The pregnant patient
10.1.1 Management of acute pain during pregnancy
professional managing the pregnancy and the health professional managing the pain.
10.1.1.1 Medicines used in pregnancy
SR Level IV
not hierarchical and that medicines in Category B are not necessarily safer than those
Paracetamol
Paracetamol is a Category A medicine and is regarded as the analgesic of choice during
NR
Level III-3 NR
Li
Level III-2
Level IV
Level III-3
Level III-3
cryptorchidism.
NR
Andersen
Level III-2
Level III-2
Level III-2
Level III-3 SR
Level III-3 SR
methodology used in each.
Level III-3
Level III-2
Level III-3 NR
Level III-2
Level III-2
Level III-2
Level III-2
Level III-2
Level III-2
NR
Level III-2
Level III-3
Level I
NR the incidence may be
Level III-3
Opioids
NR NR
NR
Level IV
Level III-2 SR
in utero
NR NR
Level III-2
10:
NR

GL
Level III-2
NR
GL
NR
Alpha-2-delta ligands
Level IV SR
Level III-2
Level III-2
10.1.2 Pain syndromes in pregnancy
10.1.2.1 Musculoskeletal pain syndromes
Level III-2
NR
Level II GL Level IV
Level IV
Level IV
Level IV
GL
Level I
Level IV
Level III-2
Level II
Level II
Level IV SR
Level II
10.1.2.2 Meralgia paraesthetica
Level III-2
NR NR
NR
10.1.2.3 Symphysial diastasis
Level IV
NR
Key messages
Use of analgesics in pregnancy
N Level I
N
Level III-2 SR
W Level III-2
N Level III-3 SR
opinion.
nd
U
Painful conditions in pregnancy
N
Level I
N Level IV SR
10:
A

B1
B2
increased occurrence of fetal damage.

B3
further details.
X
should not be used in pregnancy or when there is a possibility of pregnancy.
Notes: For medicines in the B1, B2 and B3 categories, human data are lacking or inadequate
Source:
Medicine
Opioids
C
reported with prolonged use of this class of medicines

including tramadol
A Prolonged high-dose use of codeine prior to birth may

produce codeine withdrawal symptoms in the newborn
Paracetamol A
Medicine
Aspirin C
Other nsNSAIDs
C
Coxibs
procaine hydrochloride
SSRIs: C
trimester may result in a withdrawal state in the newborn.
C
reported with prolonged maternal use of this class of
medicines.
trimipramin
10:
Medicine

taken during pregnancy also has been associated with
prior to the birth.

phenytoin sodium This medicine taken during pregnancy has been
pregnant should be encouraged to consider detailed
lamotrigine
C
medicines.
Lamotrigine
Phenothiazines:
C
disturbances in the infant.

Others:
A
metoclopramide
ondansetron
hydrobromide
tropisetron
Source:
10.1.3 Management of acute pain during labour and birth
Level I
Level IV
Level IV
Level I
10.1.3.1 Systemic analgesia in labour pain
Nonopioids
Level I
Opioids
Level IV
Level I
•
•
•
•
•
10:
Level I

Remifentanil intravenous PCA
NR
of obstetric wards use IV PCA with remifentanil as the most common agent followed by
Level I
Level II Level II
Level I
Level I
Level I Level II, or
Level III-2
depression NR
NR
Level II CR CR
CR
cardiotocograph
NR
NR
NR
10.1.3.2 Inhalational analgesia
Level I
Subgroup analysis of N
Level I
Level IV SR
Level IV SR
Level I
compared with no analgesia.

10.1.3.3 Neuraxial and regional analgesia in labour pain
Epidural analgesia
Level I
Level II Level II
Level I
Level I
Level I
Level I
Level II
Level IV
Timing of epidural
Level I
10:
Different concentrations of and different local anaesthetics for epidural analgesia

Level I
Level I
Level I
Patient-controlled epidural analgesia for labour pain

Level IV
NR
Level I .
Level I
Level II
Level II
Level II
Combined spinal-epidural analgesia for labour pain
Level I
Level I
Level II
Level III-2,
Level II
Level III-2 Level III-2,
Intrathecal analgesia for labour pain

Single-injection intrathecal opioids
Level I
7
Level I
NR
Intrathecal catheters for labour analgesia
NR
Level II
Level IV
Level IV
method for labour analgesia.
Level III-1
Level III-2
10.1.3.4 Other regional techniques in labour pain
Level I
Level II
Level I
Level II
Level III-2 Shnider
NR
10:
Level III-2
Level III-2

10.1.3.5 Complementary and other methods of pain relief in labour
Level I
Level I
Level I
Level I
•
Level I
Level I Acupuncture reduces use of
Level I
Level I
NR
Level II
Level II
Level I
•
Level I
•
Level I
•
Level I
•
Level I
•
Level I
Level I
Level I
10.1.3.6 Analgesia for forceps delivery
Level IV
Level I
Level I
10.1.3.7 Pain after Caesarean delivery
NR
Level III-
Level II
Systemic analgesia
Oral analgesia
Level I
Level II
Level II
Level II
morphine on top of background oral nonopioid analgesia found comparable analgesia and less
Level II
Parenteral analgesia
Level II
Level
II
Level II
Level II
10:
Level II

Level II
Level II
Suppa
Level II
Level II
Level II
Level II
Epidural analgesia
Level I
Level II
Level II
Level II
Level II
Level I
Level II
Level II
Intrathecal analgesia
Level I
Level II
Level II
Level II
Level III-2
Level III-2
Level II
Level II Level II
Subedi
Level II Prakash
Level II
established.
Other regional techniques
Level I
Level II
Level II
Level II
Level II
Level II
Level II
Level II
Level II
Level II
Level II
Level II
Ilioinguinal-iliohypogastric block
Level
Level II
Transversus abdominis plane block
Level I Level I
Level II Lee
Level II Level III-2 Level II
10:
Level II
Level II
Level I
Torup
PK
Level IV CR
Risk of chronic pain following Caesarean delivery
NR
Level IV
Level III-2
Level III-2
Level III-2
Level III-3 SR
Key messages
Neuraxial and regional analgesia
S
N Level I
N Level II
N
Q U
U U Level I
N Level I
N Level I
U U
Q Level I
N Level I
U
U Level I
N Level I
U Level I
U Level I
Systemic analgesia
N Level I
S
N
S Level I
N Level IV SR
N Level I
N
N
N
W Level I
N Level I N Level II
N Level I
Complementary and other methods of pain relief in labour
S
Level I
N Level I
N Level I
S Level I
N Level I
Q Level I
R N N
N Level I
10:
S Level I
N Level I
Level I
N Level I N Level I
N Level II
N Level I
opinion.
N
10.1.4 Pain management during lactation
warranted.
NR NR NR
NR NR
NR NR
NR
the maternal dose but infant medicine metabolism may be impaired and much of the data
NR
NR
administered in the peripartum period.

NR GL NR
10.1.4.1 Nonopioids
Paracetamol
The weight-adjusted maternal dose of
Level IV PK
NSAIDs
NR
NR
NR Ibuprofen is therefore considered the ideal

GL
NR
Level IV
Level IV PK Level IV PK
Level IV PK
NR
Level IV
CR
NR
NR
Level IV PK
Level IV PK
Level III-2
10:
Level IV PK Nitsun
Level IV PK
Level III-2
NR
Level IV PK
Level III-2
PK NR
Level III-2
Level IV
Level III-3
PK
Level II PK
NR Level III-2
CR
Level III-2, As
Level III-3
Level III-2
Bloor
NR
unlikely to cause harm to healthy term infants.
Level IV PK
Sauberan
Level IV PK NR
Level IV PK
Level III-3
Level III-2
Level IV PK
Level IV
10.1.4.3 Other analgesics and medications related to pain relief
PK
PK NR
Level IV Level II
Level III-3
Level IV
scores in healthy term infants.
NR
Level III-2 pidural analgesia in labour was associated with an increased risk
Level III-2
Level IV PK
CR PK
Level IV PK
Level IV PK
NR
NR
Level IV PK
NR
10:
Medicine

Opioids
Paracetamol Safe to use

Aspirin
Other NSAIDs
Ketamine Limited data

Tapentadol
SSRIs:
TCAs:
depression has been reported
SNRIs
phenytoin sodium Safe to use
consider monitoring baby for petechial rash
topiramate
Safe to use
Phenothiazines:
mother is main concern

metoclopramide
domperidone
metoclopramide
Key messages
S Level IV
S Level IV
S Level IV
opinion.
U
10.1.5 Pain in the puerperium
Level IV
Level IV
uterine pain limited mobility during maternal-infant bonding and perineal trauma and pain
Level IV
Level III-3 SR
Level IV
10.1.5.1 Perineal pain
Level IV
Level I
Level
Level I
Level I
Level II
Level I
10:
Pharmacological treatments
Level I
Level I
Level
Level II
Level II
Level I
Level II,
10.1.5.2 Breast pain
NR
Level III-1 SR
Level III-1 SR
Level IV
due to Staphylococcus aureus
Level I
10.1.5.3 Uterine pain
also decreases mean blood loss and the incidence of postpartum haemorrhage compared
Level I
Level I
Level III-2
Key messages
U Level I
episiotomy or second-degree tears reduces perineal pain and analgesic use in the
N Level I
S Level I
Q Level I
U Level I
U Level I
W Level I
opinion.
U
U
10.2 The older patient
Level IV
Level IV
GL
10.2.1 Physiology and perception of pain
NR Level III-2 NR
NR BS
10:
pain-inhibitory systems.
10.2.1.1 Neurophysiological changes
EH
NR BS
EH NR
EH
EH Level IV
NR EH
Level III-2 SR EH
Level III-3 EH
NR NR
Level III-3 EH
pain may therefore be delayed.
NR EH; NR
EH EH EH
EH Level III-2 SR
EH
NR
10.2.1.2 Clinical implications
NR NR Level III-3
EH
NR
with unstable angina.
Level III-2
Level III-2
Level III-2
Level III-2
10.2.2 Assessment of pain
10.2.2.1 Cognitive impairment
NR
NR Level IV
Dementia
NR Level III-2
Level III-2
NR Level III-2
Level III-2
10:
Level III-2 SR EH,
Level III-2

Level III-2
Delirium
Level III-2 SR
NR
Level III-2 SR
Level III-2
Level IV
Level IV Level III-2; Level IV NR
Level III-2
NR
10.2.2.2 Measurement of pain
Patient self-report measures of pain
NR; NR
Level IV Level IV
Other measures of pain
NR
NR
NR NR
NR
Level III-2
NR
NR NR NR NR
10.2.3 Pharmacokinetic and pharmacodynamic changes
concurrent diseases in older people.
EH
NR
NR BS
10:
body fat for lipophilic medicines calculate doses of
Vd t lipophilic medicines on
total body weight
muscle none
body water for hydrophilic calculate doses of

medicines hydrophilic medicines
Vd based on lean body weight
None none
Liver
medicines oral dose of some
medicines
maintenance doses
of some medicines
metabolism
Kidney clearance of renally maintenance dose of
clearance medicines with renally

of metabolites
medicines
Cardiac output central compartment
CNS Cerebral blood
metabolism the CNS but:

bolus doses of
Blood brain barrier
transport the CNS maintenance doses of
some medicines
apparent increase in
oral and
Medicines transmucosal ageing
medicines due to
none
none
transdermal hydrophilic medicines
Plasma albumin possibly changed

medicines medicines clearance and oral
cerebral uptake of
medicines possibly changed cerebral
glycoprotein
medicines
10.2.4 Drugs used in the management of acute pain in older people
when a choice of analgesic regimen is made.
NR GL
10.2.4.1 Paracetamol, nonselective NSAIDs and coxibs
GL GL GL NR
PK PK Bannwarth
PK
NR NR
Level III-3
GL
Level III-2 NR Level II
Level IV
Level III-2
10:
GL

GL NR
Level III-2
Level I
Level II EH
Level I
Level II .
Level I and
Level I Level I
Level I NR)
EH PK
NR
NR NR
Opioid dose
Level IV Level IV Level IV PK
NR
NR
Level IV Level IV
Level IV
EH It has been
NR
NR
NR
NR
NR
NR
Opioid metabolites
Adverse effects of opioids
Level IV
Level II

Level III-3
Level III-2
Level IV NR
Level III-2 PK
PK
NR
GL NR
10.2.4.4 Ketamine
There are no good data on the need or otherwise to alter
BS BS NR
BS
NR
NR
GL GL
Ahmad
NR NR
NR
Level III-2
10:

Level II
Level II
10.2.4.7 Anticonvulsants
GL
NR
NR
Level III-3

Level III-2
Level II NR
Level III-2
Level II
Level II
10.2.6 Epidural analgesia
Level I
Level II
Level II
Level III-2
Level III-2
Nygard
Level III-2
Level II
Level IV
Level III-3
Level III-1
NR
Level IV Level III-2 NR

10.2.7 Intrathecal opioid analgesia
Level I
Level IV
Level IV
Level II
Level II
depression.
Beaussier
Level II
10.2.8 Other regional analgesia
NR
10:
Level III-3

Level III-2
Level III-2
Level II
Level III-2
Key messages
S Level I
S Level I
U Level II
N Level III-2 SR
W Level III-2 SR
U Level III-2
S Level III-2
U
Level III-2
Q Level III-2
S Level III-2
U Level IV
S
Level IV
opinion.
U
10.3 Culturally responsive care for Culturally and Linguistically
Diverse patients
diaspora of many countries.
NR NR NR Level IV
Level III-2 NR NR NR Level IV
NR
NR Level III-2
NR NR NR NR
NR Level IV Level IV
Level IV
NR
NR
Level IV
10:

they know.
NR
NR Level III-2 SR EH
n
Level III-2 EH
Level III-2 EH
Level III-2 EH
Level III-3 SR
Level III-2
Level III-3

Level IV
Level III-2
NR Level III-3
NR Level III-3 SR
Level IV
NR
Level IV
Level IV NR NR
Key messages
N Level III-3
opinion.
Cultural competence of health professionals supported by cultural competency training
N
N
10.3.1 Aboriginal and Torres Strait Islander peoples
Level IV Level IV
Level IV
Level IV
10:
Level IV

NR This statement suggests
Level IV
NR
Level IV
Level IV
Level IV
Level IV
Level IV
10.3.1.1 Assessment
Level III-3
NR
Level IV
NR
Level III-3
concern regarding the ability for health professionals to ensure informed consent in the
Level IV
health professionals should be aware that periods of silence may occur following asking
NR; NR
include
• NR
• NR NR
Level IV
• NR Level IV
• Level IV
• seeking the assistance of an Aboriginal health worker or interpreter to assist in the
Level III-3; Taylor
NR
10.3.1.2 Treatment
Key messages
U Level III-3
U
Level IV
opinion.
N
10.3.2
New
NR NR
Level IV
NR
Level IV
NR NR
Level IV NR
Level IV
Level III-2 Level IV Level IV

10:
Level III-2 Crengle
Level III-2

Level III-2
Level III-2
Level III-2 Level IV Level III-2
Level IV
Level IV
Level III-2
Level IV Level III-2 Level IV

Level III-2
Level III-3
n
Level III-2
Level III-2
Level III-2
NR
Level IV
Key messages
N Level III-2
N Level
III-2
opinion.
N
N
10.4 The patient with sleep-disordered breathing including obstructive
sleep apnoea
NR
NR
NR
Chung
Level IV
NR
Loadsman
NR
Level III-2
Level III-2 SR
10:
Level III-2
database. These studies found:

•
Level III-2
•
Level III-2
•
Level III-2
•
Level III-2

10.4.1 Opioids and obstructive sleep apnoea
Level III-2
NR
Level II
GL
Blake
Level III-2
Level III-3
CR CR Level IV
Level IV CR NR Level IV
NR
Level II
Level II
GL
GL NR
10.4.2 Obesity as a risk factor
NR
Level IV
Level III-2
Level III-2
10.4.3 Approaches to treatment
Oxygen
Level III-3
Level III-3
GL
NR
Continuous positive airway pressure
GL
CR
Level IV NR
10:
Level IV
Level II Level II

de-novo
CR Level IV
NR
Level III-3
GL
Level III-2
Level III-2
Monitoring and environment
GL GL NR
Key messages
S Level III-2
SR
N Level III-2
Q Level III‐2
S Level III‐2
U Level III‐2
N Level III‐3
opinion.
N
N
S
N
10.5 The patient with concurrent renal or hepatic disease
causing direct damage and thus altering their metabolism.
10.5.1 Patients with renal disease
GL
NR NR
•
10:
•

NR NR
NR
Australian Medicines Handbook
Medicine
Opioids
Alfentanil
Buprenorphine
Codeine
impairment
recommended
during dialysis
recommended
life prolonged
dialysis
possible
Medicine
mostly in faeces impairment
would suggest that it is likely to be poorly
kidney and accumulate in renal impairment
possible
higher metabolite load
most haemodialysis procedures but may not be
delays response
end-stage renal disease
Pethidine
recommended
Sufentanil
Tramadol
renal impairment
10:
Medicine
Tapentadol

impairment
Other medicines
Local
infusions are used or repeated doses are used if prolonged or repeated
Paracetamol
Is dialysable
increase the rate of progression

to chronic renal failure
impairment
Progression of renal disease
Clonidine
has been recommended
TCAs
Medicine
ligands
10.5.2 Patients with hepatic disease
in depth.
•
•
•
decreased if use is prolonged.
•
impairment.
•
NR
NR Australian Medicines Handbook
10:
Medicine

Opioids
Alfentanil Limited data: no dose adjustment
Buprenorphine Limited data: no dose adjustment

and norbuprenorphine
Limited data: dose adjustment

clearance
Limited data: no dose adjustment
disease
Pethidine Limited data: dose adjustment
recommended
Medicine
Sufentanil
Tramadol Limited data: dose adjustment
Tapentadol
Other medicines
Local
repeated use
single dose
Paracetamol Commonly suggested that it
glutathione
Clearance is reduced
who ingest moderate to large

amounts of alcohol
disease
hepatorenal syndrome
safer
TCAs
10:
Medicine

ligands
Valproate
Key message
opinion.
U
10.6 The opioid-tolerant patient
GL
Tolerance
dependence
harm
of a drug
disorder
Diversion
OIH
Source: Adapted from (

10.6.1.1 Clinical implications of opioid tolerance and opioid-induced hyperalgesia
Level III-2
EH NR Level II
Bannister
NR
Level III-2
NR
NR Level III-2 EH
NR NR NR

Level III-2 EH Level III-2
EH Level III-2 EH Level III-2 EH Level III-2 EH

10:
In comparisons of subjects in methadone-maintenance programs with and without chronic

Level III-2 EH
Level IV EH Level III-3 EH
Level III-3 EH
Level III-2 EH
Level IV SR
Level IV SR
Level I
Level I
NR NR
CR
CR
NR
NR
NR
NR NR Level III-2
10.6.1.2 Chronic opioid use and sleep-disordered breathing
NR
Level IV Level IV
Level IV
Level III-2
Level III-3
10.6.2 Patient groups
NR
Level III-2
Level IV
NR NR
•
NR
pain.
•
NR
10.6.3 Assessment and management of acute pain
NR
NR NR NR
NR NR NR NR NR NR
•
•
•
•
10:
10.6.3.1 Assessment

• NR
NR
•
NR
•
NR
•
NR
•
NR
•
NR
NR
•
NR
disorder
Pain diagnosis
prescriber and dispensing

pharmacy
of acute pain management prescriber of any opioids

disorder
discharge
Source:
10.6.3.2 Effective analgesia
NR
NR
Opioids
counterparts.
Level III-2
Level III-2
Level IV
Level III-2
Level IV
Level III-2
NR
NR NR
NR
Level IV
NR NR
de Leon-Casasola
10:
Level III-2
NR NR

Nonpharmacological strategies
NR
10.6.3.3 Attenuation of tolerance and opioid-induced hyperalgesia
include:
•
•
•
•
NMDA-receptor antagonists
NR
BS BS
BS BS BS BS
CR
CR NR 8
Level I
Level II
Level II
Level II
Opioid receptor antagonists

Crain
BS BS BS BS
EH Level II EH
NR NR
Level I
Level II
Opioid rotation
Level IV; NR
NR NR
NR
NR NR
Adjuvants
NR
BS
Level II EH
BS BS
BS
BS BS
Level II EH
Level II Level II
NR NR
10.6.3.4 Prevention of withdrawal
NR NR
NR NR
NR
Level III-3
opioid withdrawal if a purely nonopioid analgesic regimen or tramadol or tapentadol is used
NR NR
NR NR
Level I
BS
10:
Level II
Salehi

Level III-1
Level II
10.6.3.5 Management on discharge
NR NR NR
NR
support must all be considered.

An ethical dilemma arises where the preadmission opioid regimen is not consistent with
GL
NR
Key messages
N
Level I
N
N Level I N Level I
N Level II
N Level II
S Level II
N evel II
U
N
U Level III-2
N Level III-2
opinion.
U
S
10.7 The patient with an addiction
NR
GL NR
NR
•
•
•
•
NR
NR
NR
Basu
NR
Level III-3
10:
Level IV SR
NR

NR NR
Alford
NR NR
•
•
•
•
NR NR
•
•
•
NR NR
NR
NR NR NR
NR NR
Level III-2
NR
NR
NR
10.7.1 Management of acute pain in pregnant patients with an addiction
NR
NR
NR
NR GL
NR
NR
NR
NR
NR NR
GL
NR
NR NR
increased in the third trimester because the physiological changes associated with pregnancy
NR NR
NR
NR
NR NR NR
Level III-3
NR NR NR
Level III-3
Level III-3
10:
Level III-2

NR
10.7.2 CNS depressant drugs
10.7.2.1 Opioids
Level IV SR Level III-

2
NR GL GL
NR
Level IV
NR Level IV
Level IV Level IV
NR
NR
Level III-2
Ballantyne
NR
Level IV
Level IV
Level III-2
NR
NR
NR
Level II
10.7.2.2 Alcohol and benzodiazepines
Level IV
Level IV SR
BS
Level II
Level I
NR
Level IV SR
10.7.2.3 Cannabinoids
Level III-2
Level IV
10.7.3 CNS-stimulant drugs
NR
BS
BS BS
BS
10:
Level III-2 SR

Level III-2
Level III-2
NR
10.7.4 Drugs used in the treatment of addiction disorders
NR NR
Level III-2
10.7.4.1 Methadone
NR
Level IV
NR
NR NR
NR NR
Level IV
NR NR
Level III-2 Level III-2 Athanasos

Peles
Level III-3
Level III-2
Level II
NR
10.7.4.2 Buprenorphine
Level I
NR
NR
NR
NR
with the aim of reducing parenteral abuse of the drug.
Level III-2
Level III-2
NR NR
Level III-2
Alford
NR
NR
10.7.4.3 Naltrexone
Level I
Level I
Level I Level IV
Level III-2
NR
NR NR
NR
NR
PK
Level IV
BS
NR
10:
professional.

10.7.5 Patients in recovery from addictive disorders
NR NR
NR NR
NR
NR
NR NR
10.7.6 Contribution of acute pain management to the community supply of opioids
NR
It has been suggested that the lessons learnt in the management of chronic pain should also
NR NR
Key messages
N Level I
N Level III-2
S Level III-2
opinion.
N
U
U
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Pain 15
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Aust 195
Anesth
Analg 104
Anesth Analg 112
accidental dural puncture in labour. Int J Obstet Anesth 21
Anesth Analg 96
selected topics. Pediatrics 132
367
Anaesth Intensive
Care 39
N Z Med J 115
Acute Pain
J Clin Psychopharmacol 31
Br J Pharmacol 160
Drug Use and Health: Overview of Findings
Int J Gynaecol Obstet 113

10:
21
Anaesth

Intensive Care 27
Anesth Analg 95
Anesth Analg 93
hydrocodone for postpartum pain. Obstet Gynecol 117
22
Muscle Nerve 34
analgesics. J Med Toxicol 8
Acta Anaesthesiol
Scand 44
controlled trials. 29
Pain Manag 2
outcome. Reprod Toxicol 30
240
Drugs 60
Aust
N Z J Obstet Gynaecol 47
predictors and strategies to curb opioid abuse. Pain Physician 15

J Matern
Fetal Neonatal Med 24
BMC Fam Pract 11

Geriatric anesthesiology
Thorax 57
pregnancy. 89
J Health Care
Poor Underserved 21
J Health Commun 17
rodents. Anesthesiology 85
neonatal morbidity. Am J Obstet Gynecol 107
Anesth Analg
115
Anesth Analg 94
Br J Anaesth 93
Anesth Analg 102
Arch Surg 137

Int J Obstet
Anesth 22
Anesth Analg 117

Ky Nurse 58
undergoing primary total hip and knee arthroplasty surgery in New Zealand? A registry-based cohort study.
N Z Med J 126
J Psychosom Obstet Gynaecol 27

J Opioid Manag 2

Rev 7
Cochrane
Database Syst Rev 7
Cochrane

Cochrane Database
Syst Rev 10
Arch
Intern Med 170
Paediatr Drugs 2
Clin
Perinatol 40
their physicians in primary care. J Natl Med Assoc 99

Can J
Anaesth 39
J Physiother Pain
Ass 36
Anesth Analg 118
Acute Pain 9
31
Can J Anaesth 60
use of opioids. Am J Addict 22
knowledge. Anesth Analg 116
J Pain 9
series. Int J Obstet Anesth 20

Health Care and Indigenous Australians
J Reprod Med 31
N Z Med J 117
10:
a pilot study. 96

a randomised controlled trial. Acta Anaesthesiol Scand 59
Crit Care Clin 24
Pain 75
Birth 29
J Pediatr 162
210
29
Semin Dial 24
J Opioid Manag 8
meta-analysis. BMJ 342
Anesthesiology 105
brain. Pain 154
strategies. Can J Anaesth 61
literature synthesis. Clin J Pain 24

Rev 9
the elderly. Acute Pain 8
HSS J 4
2012
labour. Int J Obstet Anesth 17

Anesth Analg 113
persistent pulmonary hypertension of the newborn. Pediatrics 131
J Neurol 251
controlled trial. Br J Anaesth 97
controlled analgesia. Anesthesiology 74

Can J Anaesth 53
Anesth Analg 66
Anesthesiology 74
J Neurol 261
24
Facts Views Vis Obgyn 5

BMJ 332
Ther Clin Risk Manag 3
Rural Remote Health

4
longitudinal randomised controlled trial. BMC Complement Altern Med 14
pain. 17
J Clin Sleep Med 3
Chest 128
J Opioid Manag 2
J Opioid Manag 7
J Pain 7
Pain Med 9
rats. J Anesth 26
Br J Anaesth 106
Obes Surg 21
abdominis plane blocks for cesarean analgesia. Reg Anesth Pain Med 39
Pain 36
J Pain 8
J Pediatr 165
Midwifery 23
Anaesthesia 65
Curr Opin Psychiatry 21
Anesth Analg 85
preliminary study. Anesthesiology 73
Curr Drug Abuse Rev 7
J Clin Anesth
24
Anesth Analg 112
Anesth Analg 102
Acta Anaesthesiol
Taiwan 48

J Clin
Pharmacol 35
10:
Anaesthesia 52

J
Clin Anesth 27
Clin J Pain 19
Can J
Anaesth 61
Pain Med

JAMA 291
J
Perinatol 34

Psychosom Med 52
People in Pain
J
Matern Fetal Neonatal Med 21
JAMA 296
Pain 144
Pain 85
BMC Geriatr 6
Appendix A
APPENDIX A
The Working Group, contributors and members of the
Multidisciplinary Consultative Committee
Working Group
Prof Stephan A Schug Chair of Anaesthesiology
Australia
Associate Professor
Associate Professor
Clinical Senior Lecturer

South Australia
Contributors
and
Prof Brian Anderson
Professor of Anaesthesiology
Clinical Associate Lecturer
Barrington
Associate Professor
Borland
Australia
APPENDIX A
Chalkiadis
Associate Professor
Consultant
Senior Clinical Lecturer
Prof Tomas Corcoran
Associate Professor
Australia
Queensland
Adjunct Professor
Consultant Neurologist
Clinical Associate Professor

APPENDIX A
Clinical Associate Professor
Conjoint Associate Professor
Associate Professor
Associate Professor
Cross-cultural trainer and consultant
Australia
Australia
APPENDIX A
Prof Philip Siddall
Prof Andrew Somogyi

Adelaide
Senior Consultant Anaesthesiologist
Singapore
Adrian Traeger Senior Physiotherapist

Senior Lecturer
Senior Lecturer
Multidisciplinary consultative committee
Member
Aboriginal and Torres

Strait Islander Liaison
Louise Quinn
Surgery
APPENDIX A
Newcastle
Clinical Pharmacology
Consumer
ANZCA
Complementary Professor Caroline

Smith
South Australia
Trauma Surgery
Neurosurgery
Adelaide
Nursing
Pain medicine specialist physician and
Pharmacology
Smith
Pharmacy
Physiotherapy
Slater
Psychiatry
Arnold
(Reviewer on
behalf of the
Australian Faculty
APPENDIX A
Appendix B
Process report
. The
NR
Development process
APPENDIX B
GL
Competing interests
Member
Prof Stephan A Schug
.
APPENDIX B
Member
Review of the evidence
acute pain were drawn directly from these.

Search strategies
searching.
Levels of evidence
GL
added.
GL
Levels of evidence
I
II
group
IV
Foreign language evidence
Preferred evidence
Secondary evidence:
GL
Level III-2 SR
Primary evidence:
APPENDIX B
GL
NR
Other evidence types:
CR GL
GL BS
PK
EH
Level II PK
Quality scoring
S
assumed.
•
Level I
•
GL
Level I
•
GL
Level I
•
Level I
Level I
Level IV SR
Examples
accomplished using a computer-
The group assignment was

accomplished by alternate
number or day of the week

Blinding
of blinding is appropriate
Incomplete masking
of blinding is inappropriate
An account of
trial is known. If there are no
data the reason is stated
was taken to account for the dropouts.
Level II
Level III and Level IV
Level IV
Cost analyses
APPENDIX B
Key messages
Updating the evidence base from the third edition of the guidelines
GL
Review and revision of key messages

New
Unchanged
Strengthened
Weakened
NB
members; there was no mandatory threshold of new evidence (eg number of
for New, U for U

Key messages
Q Level I
N Level III-3
U Level II
U Level III-1
S Level III-3
and the related key message reads:
R Level I
INN drug names

This document uses the generic names of drugs that apply in Australia and New Zealand
use within each of the chapters.

Bibliographic citations
Paediatr Anaesth 24
member of the working group.

Public consultation
The
Australian
APPENDIX B
Name
Lauren Short
Topics raised
The main topics raised in these submissions and comments related to:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Implementation, dissemination and revision
•
by editorials in professional journals.

References
Int J Technol Assess Health Care

19
BMJ 339
Lancet 354
Journal of the Royal Society of Medicine

88
methodological handbooks. Implement Sci 9

Acronyms and abbreviations
ACRONYMS AND ABBREVIATIONS

ASA American Society of Anesthesiologists
ASIC acid-sensing ion channel
ATP adenosine triphosphate
CB
CB
CIPN chemotherapy-induced peripheral neuropathy
C
CPSP chronic postsurgical pain
CT computer tomography
IC intercostal
ICB intercostal block
IL interleukin
LANSS Leeds Assessment of Neuropathic Symptoms and Signs

mL millilitre
N
NAC Nacetylcysteine
NCA nurse-controlled analgesia
NNT number-needed-to-treat
P purinergic receptor subtype
PCS Pain Catastrophising Scale
prostacyclin
PICC peripherally inserted central catheter
PPI proton pump inhibitor
prn pro re nata

SCC spinal cord compression
SCI spinal cord injury
TdP Torsades de Pointes
TNS transient neurological symptoms
TrkA tyrosine kinase receptor

g gram
L litre
mcg microgram
mcL microlitre
mg milligram
mL millilitre
mm millimetre
ng nanogram
BS basic science or animal data

CCT case-controlled trial
Index
INDEX
......................................... ....................................................................... 9
abdominal migraine ................................................. .....................................
abdominal pain................................................. ....................
analgesia and diagnosis ..................................... back pain ..........................................................
emergency department..................................... acupuncture and acupressure ...................
prehospital analgesia......................................... pregnancy ..........................................................
Aboriginal and Torres Strait Islander peoples... beliefs ........................................................................... 9
acetaminophen See paracetamol .........................................
acupuncture and acupressure .......................... biliary colic................................................................
...............................................
bisphosphonates ..............................................
...............................................
..................................... blood sampling in neonates .............................
........................................................... bone cancer See cancer pain
bone healing
burns injury procedural pain ............................. .................................................................
cranial neurosurgery ......................................... ...............................................................
day-stay or short-stay surgery ........................... ............................................................. 97
epidural ............................................................. .................
intrathecal ......................................................... ........................................................
...................... children .............................................................
spinal surgery ....................................................
..................................
adrenaline ................................................................
See
...........................................................
breast pain................................................................
......................................................
buccal route..............................................................
................................................................. buprenorphine .............................................
............................................................... children .............................................................
............................................................. 97 sublingual ..........................................................
transdermal .......................................................
allodynia .....................................................................
burns injury pain ..............................................
See children .....................................................
amantadine .............................................................. ...........................................
analgesic rebound headache .................................... calcitonin ..................................................
phantom limb pain ............................................
................................................................. cancer pain .......................................................
epidural analgesia ............................................. assessment ........................................................
............................................................. 98 bone cancer ...............................................
......................................................... breakthrough pain .....................................
.................................................. children .....................................................
ketamine............................................................
medicines ..................................................
..................................................... neuropathic .......................................................
.................................................... ....................................................
spinal cord injury pain ....................................... principles of management.................................
procedural .........................................
chronic postsurgical pain ..................................... cancer surgery ..........................................................
...............................................
neuropathic pain ............................................... cannabinoids ....................................................
............................................ ............................................................
...................................... spinal cord injury pain .......................................
............................................ .........................................................
spinal cord injury pain ....................................... ............................. 79
............................................................... cardiac pain ......................................................
migraine ............................................................ prehospital analgesia.........................................
................................................................... cardiac surgery .........................................................
........................................................................ acupuncture ......................................................
.................................................................
arnica ........................................................................ .................................................................
............................................................. 98
assessment See pain assessment
caudal analgesia in children .............................
asthma ..............................................................
......... intramuscular ....................................................
chemotherapy-induced peripheral neuropathy ........................................................
....................................................
................................ oral ....................................................................
children .........................................................
acupuncture and acupressure ................... systemic .......................................................
cancer pain ................................................ cranial neurosurgery ........................................
clonidine ....................................................
...... .................................
................................................... day-stay or short-stay surgery ..........................
................................................................. delirium ............................................................
........
............................................. denosumab...............................................................
ketamine............................................................ dental pain........................................................
lumbar puncture ............................................... acupuncture and acupressure ...........................
migraine .................................................... depression ..................................................................
...........................................................
opioids ....................................................... ...............................................................
infusions ..................................................... ........................................................
nurse-controlled analgesia ......................... spinal surgery ....................................................
............... ....................................................
........ children .............................................................
safety of parenteral use.............................. ....................................................
pain assessment ........................................
...................................................
.................................
composite scales ........................................
intellectual disability .......................... ..................................................
.. diamorphine ...............................................................
self report ........................................... children .............................................................
paracetamol ......................................................
dihydrocodeine...........................................................
dosing .........................................................
procedural pain ......................................... ..............................
regional analgesia...................................... day-stay or short-stay surgery ...........................
topical therapies ................................................ drug metabolism ..................................................
tramadol .................................................... dysaesthesias..............................................................
chronic postsurgical pain ...................................... dysmenorrhoea ........................................................
epidemiology ....................................................... acupuncture and acupressure ...........................
circumcision.............................................................. ........
clonidine ................................................................... .....
children ............................................................. ......................................
intrathecal ......................................................... ..............................
cluster headache ...................................................... ..............................................................
........................................... ...........................................................
..............................
codeine .................................................................
................................................................
.......................................................
children ....................................................... See
metabolism.......................................................... emergency department....................................
................. acupuncture and acupressure ...........................
burns injury pain ...............................................
compartment syndrome...................................
children .....................................................
.......
...................................................
........................
epidural abscess ...............................................
coping strategies ..............................................
epidural analgesia ............................................
.................................................. ............................................
children ............................................................. children .....................................................
..................................................... labour pain ................................................
......................................................... ..............
regional ..................................................... ......................................
sickle cell disease............................................... ....................................................
.............................................................. sickle cell disease...............................................
systemic ..................................................... spinal surgery ....................................................
.................................................................. epidural blood patch ................................................
children .............................................................
epidural haematoma ................
cranial neurosurgery .........................................
day-stay or short-stay surgery ........................... epinephrine See adrenaline
.................................................... .......................................................
fast-track surgery ...................................................... inguinal hernia repair ...............................................
INDEX
fentanyl................................................................. injury response .....................................................
buccal ........................................................ ...................................................
cancer breakthrough pain .........................
children ............................................................. ............................
intranasal ........................................................... clonidine ............................................................
oral .................................................................... .............................................
.............................. ...............................................................
sublingual .......................................................... intramuscular route ..........................................
transdermal ....................................................... intranasal route ................................................
.............................................. ..............................
........................................................ intrathecal analgesia ........................................
fractured neck of femur ........................................... ............................................
children .............................................................
.................... labour pain ........................................................
.............................................. ....................................................
.......................................................
chronic postsurgical pain ..................................... children .....................................................
neuropathic pain ............................................... neonates....................................................
pregnancy .......................................................... clonidine ............................................................
spinal surgery .................................................... .............................................
tonsillectomy pain .............................................
...................................................
.........................................................
........................................................... .............................................
opioids ................................................................. ......................
................................................................ irritable bowel syndrome .........................................
...................................................... ketamine
cancer pain ........................................................
......................................................... children .............................................................
........................................... chronic postsurgical pain .....................................
gynaecological surgery ............................................. emergency department.....................................
acupuncture ...................................................... intranasal ...........................................................
....................................................
haematological disorders ................................. oral ....................................................................
haemophilia.............................................................. ..............................
headache .......................................................... phantom limb pain ............................................
acupuncture and acupressure ........................... prehospital ........................................................
regional .....................................................
head and neck surgery in children ........................... sickle cell disease...............................................
head injury ............................................................... spinal cord injury pain .......................................
healing touch ............................................................ spinal surgery ....................................................
sublingual ..........................................................
.................................................
systemic .....................................................
......................................................... transdermal .......................................................
.................. labour pain .......................................................
hereditary sensory and autonomic neuropathy acupuncture and acupressure ...........................
syndromes .................................................................. .....................................
herniotomy ............................................................... lacosamide ...............................................................
.................................................... ............................................................
............................................................ migraine ............................................................
safety of pain medicines ....................................
hydrocodone ............................................................
lamotrigine ...............................................................
hydromorphone .........................................................
children ............................................................. laparoscopic colectomy ............................................
.............................. learning processes ........................................................ 9
hyperalgesia ........................................................... lipid emulsion therapy ..............................................
.......................................
hypnosis ................................................................... cranial neurosurgery .........................................
day-stay or short-stay surgery ...........................
hypotension..............................................................
epidural .............................................................
hysterectomy ............................................................ ............................................
............................................ intrathecal .........................................................
....................................... ....................................................
peripheral ..................................................
regional ..................................................... measurement tools ....................................
systemic ............................................................. procedural pain .........................................
tonsillectomy pain ............................................. ..............................................................
topical ................................................................
.................................... adrenaline .........................................................
......................... ...........................................
lower limb blocks ............................................. cancer pain ........................................................
clonidine ............................................................
............................................. .............................................
lumbar puncture in children ..................... .....................................................
magnesium ..............
intrathecal ......................................................... neurological disorders ......................................
regional ............................................................. neurological injury ....................................................
spinal surgery ....................................................
systemic ..................................................... neuropathic pain
acupuncture and acupressure ...........................
..................... .........................................
.................................................. cancer pain ................................................
massage .................................................................... ........................................................
ketamine............................................................
mastectomy .............................................................. ..............................................
medical pain ..................................................... measurement ......................................................
............................................................... membrane stabilisers ........................................
....................................................
membrane stabilisers
pregabalin..........................................................
spinal cord injury pain .......................................
spinal cord injury .......................................
systemic .............................................................
......................................................
................................
.....................................................................
meperidine See pethidine
.....................................................
.............................................
chronic postsurgical pain .....................................
methadone ......................................................... emergency department.....................................
children ............................................................. labour pain ................................................
metabolism.......................................................... prehospital ........................................................
.............................. sickle cell disease...............................................
................................................ suggested uses ..................................................
emergency department..................................... ............. See also
methylprednisolone .................................................
................................................................
regional .....................................................
migraine ........................................................... systemic .....................................................
children .....................................................
........................................................
emergency department.....................................
............................................................. ...............................................
........................................
pregnancy .......................................................... acupuncture and acupressure ...................
morphine .............................................................. burns injury pain ...............................................
.............................. day-stay or short-stay surgery ...........................
phantom limb pain ............................................ emergency department.....................................
....................................................
..........................................................
labour pain ........................................................
children .............................................................
.......... .................................
...................................................... prehospital ........................................................
musculoskeletal pain ................................................ spinal cord injury pain .......................................
..................................................................
music therapy ...........................................................
....
...................................................................
................................................................
cancer pain ........................................................
children ............................................................. emergency department.....................................
neonates............................................................ intranasal ...........................................................
............................ .............................................................
metabolism..........................................................
neonates nonsystemic...............................................
pain assessment ................................................ .................................
pregnancy .......................................................... spinal cord injury pain .......................................
INDEX
prehospital ........................................................ spinal surgery ....................................................
rectal ................................................................. subcutaneous ....................................................
sickle cell disease............................................... sublingual ..........................................................
spinal surgery .................................................... systemic .........................................................
tonsillectomy pain ............................................. tonsillectomy pain .............................................
............................................................ topical ..................................................................
children ............................................................. transdermal .......................................................
cranial neurosurgery ......................................... opioid tolerance ...................................
day-stay or short-stay surgery ........................... oral route ..........................................................
.................................................... ..............................
intramuscular .................................................... ..................................
........................................................
.................................................... ..........................................................
oral .................................................................... children .............................................................
......................................................... ................................
systemic ......................................................... orofacial pain ....................................................
............................................... orthopaedic surgery .................................................
nurse-controlled analgesia ....................................... acupuncture ......................................................
................................. total hip arthroplasty.........................................
total knee arthroplasty ......................................
..............................
.......................................................
...................................................
epidural analgesia ............................................. outcome measures ...............................................
intrathecal analgesia ......................................... ...........................................................
medicines .................................................. ..................................................................
pain assessment ........................................ children .............................................................
.............................. metabolism..........................................................
..............................
open abdominal surgery .......................................... paediatric spinal fusion ............................................
opioid-induced hyperalgesia ........ pain
....... .........................
....................................... ..............................
opioids .................................................................. .................
.................................................... ..........................................
buccal ................................................................ physiology .........................................................
burns injury procedural pain ............................. .....................................
cancer pain ........................................................ psychological factors .......................................
children ..................................................... pain assessment ...................................................
cranial neurosurgery ......................................... cancer pain ........................................................
day-stay or short-stay surgery ........................... children .....................................................
emergency department............................. composite scales ........................................
epidural ................................................. self-report...................................................
..................................................... ....................................................
.................................................... neonates....................................................
...................................................... ................................
intramuscular .................................................... measurement tools ....................................
intranasal ........................................................... physiological measures ..............................
intrathecal ........................................... ............................................
........................................................ .....................................
labour pain ................................................ pain history..........................................................
..................................................... prehospital ........................................................
metabolism.......................................................... pain measurement See also outcome measures
migraine ............................................................ categorical scales .................................................
.............................................................. ................................
.......................... neuropathic pain .................................................
............................................ ........................................
oral ............................................................ ............................................
.............................. ................................
perineural ............................................................ unidimensional measures .............................
peripheral ............................................................
......................................................... ........................................................
pregnancy .......................................................... ............................................
prehospital ........................................................ ...............................................................
pulmonary ......................................................... paracetamol .........................................................
rectal ................................................................. cancer pain ........................................................
sickle cell disease...............................................
children ............................................................. .................................................
cranial neurosurgery ......................................... .........................................................
day-stay or short-stay surgery ........................... posthysterectomy pain syndrome ............................
..................................................... postmastectomy pain syndrome ..............................
.................................................... ...........................................
........................................................ acupuncture and acupressure ...................
............................................................. .................................................
.................................................... clonidine ............................................................
oral .................................................................... ............................................
......................................................... ........................................................
................................. ..............................................
pregnancy .......................................................... membrane stabilisers ........................................
prehospital ........................................................ physical therapies ......................................
rectal ................................................................. pregabalin..........................................................
spinal surgery .................................................... poststroke pain .........................................................
post-thoracotomy pain syndrome ............................
Parkinson’s disease ...................................................
prednisolone ............................................................
............................................
..........................................
.............................
................................................................. pregabalin.........................................................
children ............................................................. chronic postsurgical pain .....................................
........................................... .................................
............................................................ pregnancy ..........................................................
................................................. spinal surgery ....................................................
medicines .................................................. tonsillectomy pain .............................................
.................................................... pregnancy .........................................................
................................................... ....................................................
psychological aspects .................................... medicines and fetal risk .....................................
safety ......................................................... migraine ............................................................
........................................................ prehospital analgesia........................................
....................... ...............................................
labour pain ........................................................
.............................................
......................................................
procedure-related pain
........................................................ 97 ..................................
................................... children .....................................................
...................................... ....................................................
neonates....................................................
perineal pain ....................................................
pruritus ...............................................................
perineural catheters .................................................
..............................
.....................................
................................................... pulmonary route ..............................................
cancer pain ........................................................ ......................................................
children ..................................................... rectal route .......................................................
clonidine ............................................................
regional analgesia
day-stay or short-stay surgery ...................
..................................
.............................................
children .............................................................
pethidine .................................................................... donor site pain in burns injury ..........................
.............................. ............................................................
phantom limb pain ................................................... labour pain ................................................
................................................................ .......................................................
prehospital ........................................................
phenytoin ................................................................. ..............
physical therapies ............................................. ...............................................................
....................................................... ..........................................................
remifentanil ................................................................
.................................................................
..................................................... ...........................................................
porphyrias ................................................................ .....................................................
........................................ renal colic .................................................................
postdural puncture headache .................................. emergency department.....................................
children ............................................................. renal disease.....................................................
postherniotomy pain syndrome ............................... respiratory depression .................................
..................................... .......................................................
rib fractures .............................................................. tramadol .....................................................................
INDEX
shingles See children .............................................................
................................................. .....................................................
sickle cell disease.............................................. ........................................................
..................................................................... .............................................................
metabolism..........................................................
skin puncture in neonates ................................ migraine ............................................................
sleep-disordered breathing ...................... ....................................................
...................................................... oral ............................................................
..............................
spinal cord compression ...................................
.................................
spinal cord injury .............................................. prehospital ........................................................
........................................................... rectal .................................................................
spinal surgery ................................................... spinal cord injury pain .......................................
steroids See
........................................... transdermal route ............................................
................................. ..............................
trigeminal autonomic cephalalgias ..........................
...........................................................
trigeminal neuralgia .................................................
subcutaneous route .........................................
triptans
......................
cluster headache ...............................................
sublingual route................................................ migraine ............................................................
..............................
umbilical surgery ......................................................
sufentanil ..................................................................
upper limb blocks .............................................
....................................................................... children .............................................................
symphysial diastasis.................................................. ..........................
tapentadol .................................................................. ................................................
temporomandibular disorders ................................. urine sampling in neonates and infants ...................
......................................................................... urologic surgery ........................................................
tension-type headache............................................. uterine pain ..............................................................
thoracic blocks.................................................. ..................................................................
children .............................................................
..................................
thoracic surgery ........................................................
....................................
thoracotomy .............................................................
................................................
thought processes ........................................................ 9
...........................
tonsillectomy ............................
white willow bark .....................................................
topical therapies
wound catheters.......................................................
children .............................................................
.............................................. .............................................
............................................................... day-stay or short-stay surgery ...........................
wounds .....................................................................

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Australian and New Zealand College

of Anaesthetists and Faculty of Pain Medicine

Copyright information for Tables 10.1 and 10.2

with permission from Prescribing Medicines in Pregnancy, 2015

AUSTRALIAN AND NEW ZEALAND

included the management of acute pain.

contributors are acknowledged as well.

is to understand and modify the pathogenic mechanisms of the undesirable responses to

Quality and Safety

necessary? Control Clin Trials 17

Curr Med Res Opin

adults. Am J Health Syst Pharm 72

clinician. J Matern Fetal Neonatal Med.

Physiother Can 63:

medicine professionals and consumers.

Cassandra Sparkes for their ongoing input to the process.

Int J Technol Assess Health Care

methodological handbooks. Implement Sci 9

apnoea ............................................................................................................ 558

SUMMARY OF KEY MESSAGES

SUMMARY OF KEY MESSAGES

SUMMARY OF KEY MESSAGES

SUMMARY OF KEY MESSAGES

U Level I N Level III-2

N Level III-2 N Level I

to use membrane stabilisers including systemic lignocaine in the management of acute

SUMMARY OF KEY MESSAGES

SUMMARY OF KEY MESSAGES

SUMMARY OF KEY MESSAGES

an increased risk of respiratory depression compared with other methods of parenteral

weakness (N) Level II

incidence of respiratory depression (S) (Level I)

Multimodal postoperative pain management

SUMMARY OF KEY MESSAGES

Acute abdominal pain

SUMMARY OF KEY MESSAGES

SUMMARY OF KEY MESSAGES

Migraine (see also Section 8.6.5)

SUMMARY OF KEY MESSAGES

SUMMARY OF KEY MESSAGES

Use of analgesics in pregnancy

SUMMARY OF KEY MESSAGES

Pain relief after Caesarean delivery

SUMMARY OF KEY MESSAGES

tyrosine kinase receptor

PHYSIOLOGY AND PSYCHOLOGY OF ACUTE PAIN

same cellular mechanisms but are independent phenomena.

PHYSIOLOGY AND PSYCHOLOGY OF ACUTE PAIN

1.2.1.2 Learning processes

Level IV Level IV with higher

impact of both acute and chronic pain.

1.2.2 Patient-controlled analgesia

Level IV Level IV Level III-1 Level IV

1.3 Placebo and nocebo effects in acute pain

1.3.1.1 Psychological mechanisms

Level II Level II Level II

this nonopioid-mediated placebo analgesia was found to be the endogenous cannabinoid

Level III-3 EH Level III-2 EH

although much more research is needed in this area.

1.4 Progression of acute to chronic pain

1.4.1 Epidemiology of chronic postsurgical pain

1.4.2 Characteristics of chronic postsurgical pain

Level IV ” was the main risk factor for the